🫠 Psychonaut POV

Welcome to Tricycle Day. We’re the psychedelics newsletter with more nuance than the green curry from your favorite Thai spot. Just as spicy, too. 🥵

Dr. Erica Zelfand has a bone to pick with the pill-shamers in psychedelic spaces—especially the practitioners. They’re not meeting people where they are. As a seasoned medical professional, she’s breaking down the unnecessary divide between Western psychiatry and psychedelic therapy.

We asked Erica what you really need to know about drug interactions, how hormonal changes affect psychedelic experiences, and why she's created retreats specifically for people on psychiatric meds.

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What's your personal story with psych meds and psychedelics, and how did that shape your approach to medicine today?

Before I got into psychedelics, I was a primary care provider. Now I joke that I'm a recovering primary care provider. I quickly learned why there's a shortage of primary care providers in the United States. What happens is that primary care providers end up actually being mental health care providers. There's still so much stigma around mental illness, despite the fact that about one in five people has a mental illness.

Even though I have training in both conventional and integrative medicine, I still felt like I wasn't able to get to a layer that my patients needed for their care. Meanwhile, I was a small business owner in the medical field, burning out and feeling disillusioned, questioning if this was even the right path. So I ended up in an ayahuasca ceremony in a living room in Portland, Oregon. The psychedelic light switch was flipped, and once you open that door, it's pretty hard to go back.

More than healing anything in that journey, I was just fascinated by what was happening in my own mind. This led to a question: should I be talking to my patients about this? Or at the very least, should I be talking to other doctors about this?

My big scary leap was presenting at grand rounds at a medical school in Portland in 2013. The topic was still very controversial then. Some people were upset at the administration for even booking me as a speaker. But one person in the audience who worked for an integrative medicine magazine invited me to write an article, and everything just exploded from there. Eventually I switched my focus to integrative mental health, and in 2022 I launched Right to Heal, which is separate from my medical practice and the retreat work I do through Rise Up Journeys.

There's a lot of conflicting advice out there about tapering off medications before working with psychedelics. What factors actually matter when determining if and how someone should adjust their medications?

First, I want to put a big disclaimer here: we don't have a lot of data. We have very few clinical trials, each of which I can critique as being rather limited. Everything I'm saying is my opinion based on deductive reasoning from available data, including working with my own clients.

Psychiatric medications, especially with regular use, change your brain. They change the number and sensitivity of receptors for different neurotransmitters. Also critically important are potential drug-drug interactions that can be harmful or even lethal. The big warning is with ayahuasca, which doesn't play well with other psych meds. Don’t try that.

With psilocybin, the data shows it works by stimulating a type of serotonin receptor called the 5-HT2A receptor. But stimulating a serotonin receptor is different from increasing serotonin levels. Psilocybin doesn't appear to increase intrasynaptic serotonin, which is a very important distinction from psychiatric drugs that do, such as SSRIs. This lack of increase in intrasynaptic serotonin with psilocybin gives us a lot of freedom, because the risk of serotonin syndrome is much lower.

This is where confusion comes in. Well-intentioned people say, "If you want to take psilocybin, you've got to stop your SSRI or SNRI." This is terrible advice. First, they probably won't have any adverse effect from combining an SSRI with psilocybin. Second, because these drugs change your brain, it isn't simple to stop taking them. You can quickly chemically destabilize someone and throw them into a horrible place that can take months to recover from. Besides, blunting lasts for months after discontinuation, so stopping an SSRI or SNRI for a week or two won't increase one's sensitivity to psilocybin anyway. I'm jumping up and down and waving my arms saying, “do not stop your psych meds!”

Beyond SSRIs, what types of drug interactions with psychedelics aren't talked about enough?

Reflux medications are under-discussed, for sure, and so are the new weight loss drugs. Proton pump inhibitors like Prilosec knock out the production of acid in the stomach. If you don't have stomach acid, how are you going to break up the mushrooms you just ate? I've seen time and again people on proton pump inhibitors don't launch. If I'm working with someone on a proton pump inhibitor, it's an automatic lemon tek.

We see something similar with GLP-1 agonists, such as Ozempic. Part of how they help you lose weight is they help you feel full longer by slowing the rate at which your stomach processes food. If you have delayed gastric emptying, you won't absorb the medicine at a rate fast enough for a consistent experience. I heard about someone on a GLP-1 agonist who felt nothing at an Oregon service center, but then started tripping in their taxi ride home four hours later.

Mood stabilizers are another concern. They put a floor and ceiling on nervous system excitability, and that ceiling includes the psychedelic experience. When somebody on a mood stabilizer wants to work with me, I typically ask them to work with their prescriber to lower the dose—not stop it—so the mushrooms can have an effect.

As for benzos, they’re trip killers. They blunt the psychedelic experience, but if someone uses benzos regularly and stops, that withdrawal can be life-threatening. That said, they can be a godsend for mania following psychedelic use. A well-timed benzo can make the difference between therapeutic integration and hospitalization.

You work with perimenopausal and postmenopausal women in your practice. How do hormonal changes affect psychedelic experiences?

Women who've had psychedelic experiences through their reproductive years and then hit perimenopause sometimes report that their trips aren't as powerful, fun, or visual as they used to be. When I have a retreat with postmenopausal women, I budget more medicine for that group. We had one woman who needed 17 grams to launch on our last retreat. Another took 21 grams and still didn't launch, so we did holotropic breathwork with her, and that worked.

What happens in menopause is that the ovaries retire, so the body doesn't have as much progesterone or estrogen. Progesterone is a calming neurotransmitter. It hits the same GABA receptor as alcohol and benzos. This is why we see more anxiety and sleep issues in menopause.

One of the things estrogen does is it helps sensitize the serotonin receptor. This is why many women do okay with their mental health until they hit menopause. The limited data we have suggests there's probably a synergistic effect between hormone replacement therapy and psychedelics. I think when it's my turn, microdosing plus hormone therapy is probably what I'll be doing.

Tell us about your retreats. What motivated you to create spaces specifically for people on medications who want to work with psychedelics?

There are just so many of them. When I teach facilitation and we discuss psychiatric-psychedelic interactions, I joke: "If you want to only work with people who aren't on psych meds, that's fine, and I wish you and your three clients the best of luck."

Are there many people who are overmedicated? Yes, absolutely. I'm not saying everyone on a psychiatric medication is being served by that prescription. But if they're seeking out psychedelic healing, it means they're still suffering. I'm motivated to help those people without making them suffer more. Healing doesn't have to feel like a punishment.

Many retreat companies have policies where if you're on any psychiatric medication, you can't come on their retreat. A lot of these practitioners don't have medical training, so these considerations aren’t in their scope. Maybe they're coming from an abundance of caution. But that approach leaves a huge number of people who need care underserved, and supporting them has meant exploring the fringes of what can be done.

There's a lot of judginess in the psychedelic industry around pharmaceutical use. I don't think any one drug class can treat everything, and that includes psychedelics. I would like to see more nuance and tolerance in the psychedelics industry around pharmaceutical use, and more nuance in the pharmaceutical industry around psychedelics.

Want more from Erica?

Schedule a consultation to talk about what other doctors won’t talk about, or check out her upcoming retreats.

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DISCLAIMER: This newsletter is for educational and informational purposes only and is not intended as a substitute for professional medical advice. The use, possession, and distribution of psychedelic drugs are illegal in most countries and may result in criminal prosecution.