Non-prescription addiction: A brief look at nasal spray dependence

I’m not quite sure about how I came across it, but I unearthed an article on the Discovery Fit and Health website entitled ‘Can nasal sprays be addictive?’ Apparently Oprah Winfrey did a whole episode of her show on the phenomenon (but I must have missed that one). The article noted that nasal sprays (such as Sinex) contain decongestants (such as oxymetazoline, xylometazoline and ephedrine) that constrict the blood vessels inside the nose. More specifically:

“When you have a cold, the flu or allergies, these blood vessels become swollen and dilated. This stimulates the nasal membranes to produce large amounts of mucus. Like stepping on a garden hose, constricting the blood vessels reduces the blood flow to your nostrils. The swollen vessels shrink, and this helps to dry things up. Unfortunately, your nose can become tolerant to the decongestant’s effect if you use it for too long. Tolerance in general happens because your body launches a biological counterattack against the effects of a drug”…You end up using more and more to get rid of your stuffy nose. And each time you sniff more decongestant, your body redoubles its efforts against the resulting constriction”.

The labelling on nasal sprays typically advise not using the product for more than three days in a row because of the diminished effect as the tolerance to the decongestant properties builds up. Anecdotal accounts of ‘nasal spray addiction’ appear quite often in the popular press. For instance, a 2008 story in the Daily Mail recounted the story of 27-year Gloucestershire woman Allyson Forbes, a hay fever sufferer who claimed to be addicted to her nasal spray. Dr George Du Toit, a London-based allergy consultant was interviewed for the story and was quoted as saying:

“These products are not actually addictive in the true sense of the word – you cannot develop a chemical or physical addiction – but they are psychologically addictive because of the initial relief they induce…Patients need increasing doses of the medication to achieve the same response. This rebound condition is called rhinitis medicamentosa (RM), where permanently swollen intranasal tissues can damage the lining of the nose. The products should not be used for longer than seven consecutive days…RM typically occurs after five to seven days of use”.

Another person interviewed for the story was the chemist Sultan Sid Dajani (Royal Pharmaceutical Society) who said:

“People often don’t want to talk about this kind of dependence because they are embarrassed. Chronic abusers who are long-term users of these medications, known as nasodilators, are committing an unwitting form of self-harm and I feel every sympathy for them. On average, I see five people a week who have this problem and I’m an independent chemist, so goodness knows how many there are regularly buying in chains and supermarkets. Addictions to these nasodilators are more common than addictions to over-the-counter medicines, such as codeine”.

Allyson said she had to use her nasal medicine four times a day and says she doesn’t “feel physically addicted” and knows that the addiction is psychologically-based and “is in [her] head”. If you feel you may be suffering from an addiction to nasal sprays are even articles on the internet that claim they can help you such as ‘How do you beat a dependency on nose spray?’ (at the Wiki Answers website). There’s even a totally dedicated website that deals with treating nasal spray addiction (AfrinAddiction.com). Other stories (such as one at the Medical News Today website) sensationally claim that “millions suffer from addiction to [over-the-counter] nasal sprays” while a story in the New York Times ran the headline “Nasal sprays can bring on vicious cycle”.

Looking at the psychological and medical literature, there is a lot less that has been published on whether nasal sprays can be addictive. However, there is actually quite an established literature on psychiatric conditions associated with respiratory drugs (including decongestants found in nasal sprays). Dr. Richard Hall and colleagues in a 1985 issue of the journal Psychosomatics reviewed the incidence of psychiatric reactions to medically prescribed and over-the-counter respiratory drugs. The concluded that such psychiatric conditions are most associated with heavy and chronic users of such drugs. However, they also found that toxicity was scarce and poorly defined.

In relation to addiction, I only managed to locate three academic papers that reported ‘addiction’ to nasal sprays. In a 2006 issue of Journal of Investigational Allergology and Clinical Immunology, Dr. J.T. Ramey and colleagues reviewed the literature relating to rhinitis medicamentosa (RM). They noted that:

“Psychological dependence and an abstinence syndrome consisting of headaches, restlessness, and anxiety following discontinuation of nasal decongestants have been reported, leading some authors to use the word ‘addiction’ when describing this syndrome”.

Dr. Ramey and colleagues’ paper based this observation on three case reports published between 1969 and 1984. One case was reported by Dr. M. Pearson and colleagues in a 1969 issue of the American Journal of Psychiatry. They described a man with rhinitis medicamentosa who carried four gallons of phenylephrine aboard a wartime ship because of his addiction to this medication. In another case study reported by Dr S. Snow and colleagues in the British Journal of Psychiatry, toxic psychosis was highlighted in a 26-year old male patient said to be addicted to phenylephrine in nasal spray form. The man was also reported as experiencing tactile and visual hallucinations, visual illusions and paranoid delusions. These papers suggest the possibility of addiction to nasal spray but given the fact so few case studies have been reported in the medical literature, the incidence would appear to be very rare (and certainly not the “millions” reported in some website stories).

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Discovery Fit and Health (2013). Can nasal sprays be addictive? Located at: http://health.howstuffworks.com/mental-health/question546.htm

Estridge, B. (2008). Hay fever has left me addicted to nose spray. Daily Mail, September 6. Located at: http://www.dailymail.co.uk/health/article-1053096/Hay-fever-left-addicted-nose-spray.html

Fleece, L., Mizes, J. S., Jolly, P.A., & Baldwin, R.L. (1984). Rhinitis medicamentosa. Conceptualization, incidence, and treatment. The Alabama Journal of Medical Sciences, 21(2), 205.

Hall, R., Beresford, T., Stickney, S., Nasdahl, C., & Coleman, J. (1985). Psychiatric reactions produced by respiratory drugs. Psychosomatics, 26, 605-616.

Pearson, M.M. & Little, R.B. (1969). The addictive process in unusual addictions: A further elaboration of etiology. American Journal of Psychiatry, 125, 1166-1171.

Ramey, J.T., Bailen, E., & Lockey, R.F. (2006). Rhinitis medicamentosa. Journal of Investigational Allergology and Clinical Immunology, 16(3), 148.

Snow, S.S., Logan, T.P., & Hollender, M.H. (1980). Nasal spray’ addiction’ and psychosis: A case report. British Journal of Psychiatry, 136, 297-299.