The blog post discusses the recent stoppage of the production of Bupropion (Zyban) and Varenicline (Champix) due to the detection of impurities that could increase the risk of cancer. Alex, who suffers from chronic depression, argues that the benefits of the antidepressant outweigh the minimal risk of cancer. Alex also criticizes the lack of availability of alternative treatments for depression and smoking cessation, particularly MAOIs and the lack of supply of smoking cessation drugs in the UK. Alex questions the logic of discontinuing acute treatments for smoking cessation due to a small risk of cancer over a few months.

Imagine the scenario. Potential impurities are found in some HIV retroviral drugs that produce a small increase in the probability of contracting cancer over their lifetime. I think the last thing you would expect would be the immediate stoppage of the production of the antiretroviral drugs in question. Leaving a patient vulnerable to imminent death as HIV progresses to AIDS is of greater importance than a tiny increase in lifetime cancer risk.

Yet, in the world of mental health treatment, this type of scenario has recently unfolded with the stoppage of the supply of Bupropion (Zyban) in the UK, leaving me and many others without the drug keeping them out of depression.

On the outside, it might seem a bit drastic for me to compare treatment for a deadly illness like HIV/AIDS and treatment for depression. Except that depression is very much a deadly illness – that antidepressants treat.

We tend to think of suicide as some sort of choice. After experiencing the horrors that depression has to offer I can almost certainly say it is not one. As much as you might think that you could continually “will” yourself alive, depression will envelop this pitiful excuse of a concept and bury it far out of reach.

I think something almost everyone is guilty of, including me for a while, is thinking that antidepressants are somehow all the same. I’ve read many blog posts, such as this one which generalises a personal experience with a specific (or collection of) antidepressant(s) and applies it to the entire drug category. It is an easy mistake to make given the selection of anti-depressants is disproportionally SSRIs and serotonin-acting medications. They might have taken two or three different antidepressants e.g. escitalopram, Sertraline and fluoxetine thinking they did different things, when their method of action is, arguably, pretty much the same.

I believe that the above misconception is one of the many reasons the advice is almost always “use an alternative” when a supply of an antidepressant is stopped. This is fine if the antidepressant in question is an SSRI (selective serotonin reuptake inhibitor), but bordering cruel otherwise.

This was exactly the case when the major supplier of the MAOI (MonoAmine Oxidase Inhibitor) Phenelzine, stopped production in 2019, giving the advice to switch to an alternative or wean off of the drug. It was astounding incompetence.

No other MAOIs, to my knowledge, were available. Further, the mechanism of action of MAOIs, the inhibition of the Monoamine oxidase (the enzyme that removes monamines – i.e. Serotonin, dopamine, noradrenaline) is entirely different to the selective reuptake inhibition action of most other antidepressants. Users became dependent on phenelzine. I suppose it can be seen almost as like insulin. Coming off of the drug takes an inordinate amount of time (months) and if someone is on an MAOI it is likely they would have tried everything else.

The supply problem of Zyban was something I had always feared. As, in the UK, it is not licensed for depression. Somewhere over the Atlantic it magically turns from an antidepressant into a smoking cessation drug. It makes, however, the supply halt all the more perplexing.

The only other smoking cessation drug, Varenicline (Champix), has also been off the market since October 2021 never to be seen since. So at the minute, there are no smoking cessation drugs available in the UK.

If we use previous examples of medications found to have nitrosamines (e.g. Valsartan, Nizatidine, Metformin etc.), the potential increased risk of cancer is minimal. According to the FDA, if 8000 people took contaminated Valsartan at the highest dosage every day for four years, there would be one case of cancer. If we assume that the nitrosamine impurities within Bupropion and Varenicline are within the same ballpark, I think it would be safe to say there would be a lot more cases of cancer if those 8000 people smoked a pack of cigarettes a day instead.

But the astounding thing is that Varenicline and Bupropion are not chronic treatments for smoking cessation. They are taken for a total of 9 weeks for Bupropion and usually 12 – 24 weeks for Varenicline. Bupropion has been off the market for three months and Varenicline since June 2021. So, the two acute smoking cessation drug treatments used to help people stop dumping a whole load of cancer-causing chemicals into their bodies have been stopped for (likely) years because of an almost zero increased risk of cancer over the space of a few months.

Uhhh, What?!

I’m not sure the logic adds up. Coming off any drug is hard. Coming off addictive drugs is exceptionally difficult and painful. Patients need all the help they can get.

As for me, I would most definitely take the small increased lifetime risk of cancer to keep myself out of chronic depression. I would hazard to guess this would be the same for most who have suffered major chronic depression. It is a no-brainer.

The worst case scenario is Bupropion is pulled from the market entirely, all over the world. Like many previous instances of nitrosamine impurities, Zantac, for instance 1 Bupropion may be determined unsafe – or rather, too expensive to fix.

So, I am left in uncertainty again. At the time of writing (Early January), I had just started to get my sharpness of mind back – the stress has thrown that out of the window. I have a supply until April. But after that, I don’t know what I am going to do. It makes me angry more than anything. I hate unnecessary hurdles. How many more days of my life is the mental health system going to take from me?

  1. though it is a special case because the problem was not to do with production, instead it degraded into the cancer-causing chemical NDMA under certain conditions in storage