Thanks for your comment. You bring up some tough questions and I don’t really know all the answers. But I’ll tell you my reasoning, right or wrong.

I agree that my obligation is to my patient first. That’s why from the very start I gave him a prescription for the Zyban. I want him to quit smoking, and if the medicine helps (it only has a meager rate of success at one year out) then I’m delighted. But put in context, it’s not a miracle life-saving medicine.

Why Zyban and not Wellbutrin? Many reasons. One is for accuracy in the medical record. Writing for Zyban makes all current and future readers of the chart aware why the patient is taking it and gets rid of any confusion over the diagnosis. Using the name Zyban also allows for better safety. Zyban is used at a standardized dose, while Wellbutrin comes in three different formulations and multiple dose levels that could be accidentally interchanged. Moreover, using the name Zyban cuts the risk of overuse. Unfortunately, when a patient is started on a medicine intended for short-term use, without proper attention the medicine can easily get refilled longer than intended. The problem is that Wellbutrin can be used indefinitely, while Zyban is used about three months then stopped. Because of the low but real risk of seizures and other medication reactions, it’s best to use the Zyban for the shortest course necessary. Using the name Zyban hopefully helps the doctor stop the medicine after the appropriate short interval.

I don’t know the actual reason why Zyban and Wellbutrin, the same medicine, have different names. I’ve heard many rumors, and in my post I decided to use the one about stigma with respect to depression. To be fair, that is certainly not the whole answer. The reason is probably a combination of the safety issues I mentioned above, marketing (the depression stigma), patent issues, profits, and other reasons I don’t know. I’d like to read a thorough independent analysis of the issue.

Back to the patient: he didn’t really have mild, intermittent depression. That was a white lie her used to lobby for the Wellbutrin. Also, if the medicine was important to him, he could have bought it that first day. He doesn’t need to rely on his insurance. We all must take responsibility for our own health. And the money he could save by not having to purchase cigarettes would more than cover the cost of the prescription. He wouldn’t lose a cent.

Doctors don’t have control over insurance companies. (I wish we did, but we’d probably make just as many poor choices.) The insurers constantly change their preferred medications based on what they deem is best for themselves and their patients. I’d like to think patients have some control over their insurer. They can switch insurance if it doesn’t cover the services they want. But we all know it’s not that simple. And many of my patients (and I myself) purposefully choose the cheapest plan in hopes of saving money. We often get what we pay for.

Another issue that I didn’t mention in my post is that when I write a prescription for Wellbutrin, I usually get a form faxed to me from the patient’s insurance asking if the drug is intended for smoking cessation or depression. Lying about the reason is insurance fraud, and could result in the loss of my medical license. I fill out the form honestly.

In the end, I can see people disagreeing with my decision. But it’s certainly a complicated issue.

I agree that my obligation is to my patient first. That’s why from the very start I gave him a prescription for the Zyban. I want him to quit smoking, and if the medicine helps (it only has a meager

I disagree with you about the Zyban thing, though. Did the drug company really relable Wellbutrin as Zyban to help people avoid the stigma, or because they figured they could get more money for it by selling it as a different product with a different FDA-approved use? Are there patent issues involved that help them get a longer hold on their intellectual “property” by creating Zyban?

And why will the insurance company pay for one and not the other? Quitting smoking sounds like about as important a thing as treating mild, intermittent depression — at least they’re both admirable things for a doctor to be involved with.

It sounds like either the drug company or the insurance company or both has made decisions that are motivated by profit to the detriment of the patient’s welfare. As a doctor, your obligation is first to your patient. And as a human being, your obligation is first to another human being, not a corporation. In your place, I’d have prescribed the Welbutrin without qualms.