Can you really get addicted to nasal spray?

Nasal spray - sold in New Zealand under brand names like Otrivin, Dimetapp and Sudafed - also known as Afrin overseas - aims to ease congestion, but can paradoxically make it worse if you take it longer than recommended.

Packaging warns not to use these sprays for longer than three days, but if you’re caught in the grip of a never-ending head cold, you may find yourself using it longer - and end up with what’s known as “rebound congestion".

Rebound congestion sees your nasal passages adapt to the drugs in nasal spray, causing blood vessels to dilate and the tissues in your nose swell when you suddenly stop using them.

Nasal sprays are marketed in New Zealand with some warnings about the dangers of overuse, but ultimately the responsibility comes down on the consumer to carefully monitor their own usage.

The internet is filled with tales of people finding themselves hooked on nasal sprays and trying to get off.

“I literally cannot breathe,” one person wrote on the busy Reddit support group ‘Quit Afrin’.

Some people have reported they’ve ended up hooked for years - “I used Afrin for about 10 years,” one Redditor wrote, while another said, “I have been reliant on decongestant nasal sprays for 26 years. I have tried cold turkey but unsuccessful.”

Can nasal spray really be addictive?

There are multiple kinds of nasal spray - we’re not talking about saline nasal sprays or steroid nasal sprays like Flixonase.

The ones that can cause issues if used excessively are over-the-counter congestion remedies marketed here as ‘12-hour nasal sprays’.

What they have in common is their ingredients.

“The common OTC decongestant sprays contain oxymetazoline (eg. Dimetapp) or xylometazoline (eg. Otrivin),” said Nic Bodenstein, an ear, nose and throat specialist and surgeon based in Auckland.

“They provide welcome relief from nasal blockage in the context of a cold.”

Those substances are vasoconstrictors, which causes blood vessels to constrict in the nose. Narrowing the blood vessels reduces the blood flow, which in turn reduces swelling and congestion in the nasal tissues, making it easier to breathe.

If you use longer than recommended, they can cause dependency.

“Getting people to abandon their dependency on these sprays can be very difficult,” Bodenstein said. “They continue to pursue relief from mouth-breathing, snoring and anxiety-driven breathlessness.”

It can create a vicious cycle of continuing use.

“Periods of relief become shorter and shorter prompting more frequent use of the sprays.”

What are the rules on their sale?

A spokesperson for regulatory body Medsafe said, “Outside of a few exceptions, oxymetazoline and xylometazoline are considered pharmacy-only medicines”.

“This means they must be sold at a pharmacy, but do not require a pharmacist to be involved in the sale”, they said. “This gives patients the opportunity to ask for advice if needed.”

That restriction can be pretty loose in reality.

This reporter, during repeated bouts in the past with colds and allergies, only rarely had a cashier or pharmacy worker offer any advice about using decongestant nasal sprays or warnings about how long to use them.

In comparison, the powerful decongestant tablet pseudoephedrine was reintroduced for sale over the counter in New Zealand in 2024, but is sold behind the counter and requires speaking to a registered pharmacist.

“All oxymetazoline and xylometazoline products in New Zealand are required to have warnings on package labels advising people not to use them for more than three days in a row,” the Medsafe spokesperson said.

But is the small print on packaging enough?

“I feel the most effective messaging would be advice from the pharmacist (which may not happen if medications are sent by courier or picked up by the family or friends of the person suffering a cold),” Bodenstein said.

“The need to limit the duration of treatment should also be stated in advertisements for the products.”

Bodenstein said the products should definitely be used no longer than five days.

“In some countries the packaging must contain 'Patient Information Leaflets' to this effect but this is not a requirement in New Zealand and one might question how many patients would bother to read the leaflet.”

You can also pick up sprays containing oxymetazoline at non-pharmacy locations marketed under names like Vicks Sinex at The Warehouse, but it must be a lower strength - “as long as it contains 0.05% or less and the pack is no more than 20 mL”, according to Medsafe.

So how dangerous is rebound congestion?

Rebound congestion, also known as rhinitis medicamentosa, is unpleasant, but can be reversed.

However, more serious complications have been reported.

At its very worst, prolonged usage of sprays can lead to chronic sinusitis, perforation of the nasal septum or damage to the tiny turbinate bone structures inside the nose, noted a recent article for The Conversation by Dipa Kamdar, a senior lecturer in pharmacy practice at Kingston University in London.

“Truly irreversible mucosal damage is probably rare,” Bodenstein said.

In April, the UK’s Medicine and Healthcare products Regulatory Agency issued a drug safety update noting “increased risk of rebound congestion, rhinitis medicamentosa, and tachyphylaxis with overuse” and recommended patients and caregivers should not “exceed the recommended dose and not to use for more than five consecutive days”.

It said that “continued use can also lead to more serious and longer-lasting changes to the lining and structures of the nose”.

Medsafe said no similar online warning was planned for New Zealand, and noted the recommendation for just three days of use instead of five was already lower than the UK.

How can you get off these products if you think you’re hooked?

If you’ve been using nasal sprays for many weeks - or even months or years - the key is to cut back your usage as soon as possible. But that can be difficult if it feels like you’re drowning in your sleep.

ENT physicians like Bodenstein and other nasal specialists offer a variety of tips for getting out of the nasal spray overuse cycle.

Going “cold turkey” will work, but many advise gradually tapering off use instead.

The “one nostril” method is considered successful by many - using spray only on one side for several days or longer, while letting the unsprayed nostril recover, and then letting the other nostril gradually heal after that.

Bodenstein said recovering from nasal spray overuse requires patience.

“Weaning people off their dependency requires a period of blockage on their way to recovery.”

Some experts also advise diluting nasal sprays by adding sterile saline nasal spray to the solution in an increasing ratio to wean off of it.

Humidifiers, regular saline rinses with neti pots and oral decongestants can help. Elevating your head some while sleeping can also reduce night time congestion.

Others sing the praises of switching to a steroid spray such as Flixonase.

Nasal steroid sprays work differently than decongestant sprays such as Otrivin, and have fewer side effects or risk of rebound congestion. They do require regular use for at least a few weeks rather than the “quick hit” that decongestant sprays deliver.

This might be eased by steroid nasal sprays and antihistamines but the desire for a 'quick fix', even for a very short period, has many people reaching for their decongestants.

Many people are plagued by allergies that cause congestion instead of a cold, but those people shouldn’t reach for the decongestant sprays, Bodenstein said.

“Allergic rhinitis can itself cause prolonged nasal blockage but treatment should avoid decongestant sprays in favour of steroid sprays, antihistamines, desensitisation programmes or occasionally even limited nasal surgery.”

While there are many homegrown methods of kicking nasal spray addiction that can offer results, it’s also recommended to consult your GP or an ENT specialist if congestion continues to linger, as there could be several other causes involved.

“Anyone who has been using nasal sprays for longer than the recommended time should consult a healthcare professional,” the Medsafe spokesperson said.

“There may be an underlying issue causing your symptoms, and a healthcare professional can help you find the most effective treatment.”

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