In August, the New England Journal of Medicine published a letter to the editor by Boyer, Shannon and Hibberd entitled "Web Sites with Misinformation about Illicit Drugs".¹ In this article, Boyer et al. criticize government websites for not competing successfully with "partisan" drug information web sites, name sites they consider partisan, and offer specific criticism of information found on those sites.

To the Editor of the New England Journal of Medicine: In their article discussing online drug information resources, Boyer et al. express concern over a comment made on Erowid.org that taking an SSRI after Ecstasy may reduce the risk of MDMA neurotoxicity.1 They state that taking an SSRI after MDMA might lead to serotonin syndrome, but their concern is unsubstantiated. SSRI coadministration has been practiced by MDMA users for many years, without evidence of serotonin syndrome, as documented by published papers2 and dozens of unpublished reports collected by Erowid. Additionally, one clinical study administered 1.5 mg/kg MDMA (po) after citalopram with no evidence of increased medical risk (3). By blocking MDMA interactions with the serotonin transporter, SSRIs reduce the physiological and experiential effects of MDMA in humans2,3 and neurotoxicity in rodents.4 This includes attenuation of both heart rate and blood pressure increases. No drug or drug combination is without risks. At least one adverse event (not involving serotonin syndrome) has been reported after this combination.5 Attempting to decrease risk of MDMA neurotoxicity with an SSRI may increase other risks, but serotonin syndrome is not known to be one of them. The well meaning but misinformed concerns of Boyer et al. illustrate why many people rely on Erowid.org and other alternative information sources rather than biased "anti-drug" or government-sponsored sites. Unlike those sources, the Erowid.org archive maintains reliability through literature reviews, expert critiques, interviews with users and input from readers. We welcome comments and corrections. 1. Boyer EW, Shannon M, Hibberd PL. 2001. Web Sites with Misinformation about Illicit Drugs. N Engl J Med 345:469-471. 2. Stein DJ, Rink J. 1999. Effects of ‘Ecstasy' blocked by serotonin reuptake inhibitors. J Clin Psychiatry 60:485. 3. Liechti ME, Vollenweider FX. 2000. The serotonin uptake inhibitor citalopram reduces acute cardiovascular and vegetative effects of 3,4-methylenedioxymethamphetamine (‘Ecstasy') in healthy volunteers. J Psychopharmacol 14:269-74. 4. Shankaran M, Yamamoto BK, Gudelsky GA. 1999. Involvement of the serotonin transporter in the formation of hydroxyl radicals induced by 3,4-methylenedioxymethamphetamine. Eur J Pharmacol 385:103-10. 5. Lauerma H, Wuorela M, Halme M. 1998. Interaction of serotonin reuptake inhibitor and 3,4-methylenedioxymethamphetamine? Biol Psychiatry 43:929.

The authors made several comments about Erowid.org, pointing out the large amount of traffic the site gets, as well as implying that the information we provide is both less reliable than government sponsored anti-drug websites and likely to cause harm.

Boyer et al. cite a study (Wax 2000) which looked at the effects of internet drug information on the use of drugs by students. Their letter states that this study found:

"24 percent of college students used the Internet to obtain information on illicit substances, and 27 percent of Internet-using college students reported that Internet use increased the likelihood that they would use drugs."

While this certainly implies that drug use increased after exposure to information on the internet, a closer examination of the study cited reveals that an even higher percentage of students reported that internet drug information reduced the likelihood that they would use illicit drugs.

From the study itself, 168 students were surveyed (94 college and 74 first year medical students). Nineteen percent reported having used the internet to find information on recreational drugs (24% college and 14% medical). Of those who surfed for drug information, 9% said this increased their likelihood of using recreational drugs (27% college and 0% medical) while 19% said it decreased their likelihood of using recreational drugs (27% college and 10% medical).²

Boyer's primary criticism of Erowid was in reference to a comment made about the potential use of SSRIs to reduce negative side effects of MDMA. They commented that "The combined use of SSRIs (selective serotonin reuptake inhibitors) or MAOIs (monoamine oxidase inhibitors) with drugs possessing serotonergic activity such as MDMA has led to serotonin syndrome in selected patients."

While it is true that combining MAOIs with MDMA increases risks of serotonin syndrome, there is little evidence to suggest the same is true about SSRIs. We submitted a formal response to the New England Journal of Medicine (below) which they declined to publish, citing space limitations.

It should be noted that Boyer's original submission was a 30 page article cut to two pages by the editors of the NEJM. It is unclear whether the problems with the final content were part of the original or a result of these cuts, but we were disappointed that the NEJM would publish such a letter and not allow space for a response.