Very few drugs relieve a symptom as speedily as an over-the-counter decongestant nasal spray clears a stuffy nose.
A couple of squirts can shrink swollen tissues in seconds to minutes, letting in an exhilarating rush of fresh air. With some sprays, a single dose works for as long as 12 hours.
But relief provided by nasal spray decongestants like Afrin and Neo-Synephrine comes at a price: the risk of rebound congestion caused by overuse and, for some people, a vicious cycle of overuse and dependence that feels like an addiction.
"It works so well that you tend to keep using it," says Dr. David Vernick, an ear, nose and throat specialist at Beth Israel Deaconess Medical Center in Boston. "You're used to breathing well with the spray, and when you stop it, you get congested. So you use it a little more frequently, yet the congestion doesn't clear up for long."
That's because after three or four days of continuous use, the sprays can cause the nasal linings to swell up again, even when the cold or attack of sinusitis or allergy that originally caused the problem has passed. If this pattern continues, a patient has a good chance of becoming trapped in a vicious cycle of overuse and dependence that can last for months or years.
Confessions of nasal spray addiction now crop up regularly on Internet discussion forums: one site, afrinaddiction.com, markets a book of tips for kicking the habit.
Clayton Traylor, who started the Web site in 2005, said he had used nasal spray "off and on" for chronic sinus trouble since he was a child.
"I got addicted many times, quit cold turkey and then started back again," said Mr. Traylor, who lives in Birmingham, Ala.
Whether a dependence on nasal sprays is a true addiction is arguable, but some doctors point out that, as with drugs of abuse, people who are hooked on nasal decongestants tend to use more and more and to suffer withdrawal symptoms if they try to stop.
"It's pretty common," says Dr. Neil Bhattacharyya, associate professor of otology and laryngology at Harvard and Brigham and Women's Hospital.
He added: "I'd say that one out of every seven patients with sinus and nasal obstruction have abused nasal sprays. They say it's the only way they can sleep at night."
Doctors call nasal stuffiness and blockage that are caused more by the treatment than the original problem rhinitis medicamentosa, a term coined in 1946. The problem can easily fly under the radar of a standard medical exam, said Dr. Stanley Goldstein, an allergist in Rockville Centre, N.Y.
"Often the patient doesn't mention a nasal decongestant when listing his medications, because it's over-the-counter," Dr. Goldstein said. He says he diagnoses the disorder several times a month in his practice.
"You have to ask them," he said, "and ask how many bottles they have. They'll have them everywhere, in the house, in their car, in their briefcase, in their desk. They cannot function without the drug."
Dr. Goldstein recalled a patient who admitted going through the host's medicine cabinet at a party until she found a bottle.
Rebound congestion is a risk with decongestants that contain one of two compounds that shrink spongy, swollen nasal membranes by constricting the network of tiny blood vessels within them.
Phenylephrine, a short-acting vasoconstrictor, is the active ingredient in Neo-Synephrine, a medicine cabinet staple since it entered the market in 1940. A longer-acting compound — oxymetazoline and xylometazoline — appeared in the 1960's and is responsible for Afrin's advertised 12-hour relief. (There is also a formulation of Neo-Synephrine containing oxymetazoline.)
"Afrin is safe and effective when used for three days," said a spokeswoman for its maker, Schering-Plough. "We do not support extended use of this product."
Though it is not entirely clear why, the blood vessels in the nasal lining quickly become tolerant to the drugs' shrinking effects. With months of overuse, the sprays choke off blood flow to the nasal membranes and damage them. In some patients with severe cases, Dr. Bhattaharyya said, "the inside of their nose looks like a chemical burn."
Dr. Goldstein said he had seen patients with holes in the nasal septum — the structure that separates the two breathing passages — from abuse of the decongestants.
Decongestants do not solve the problem that prompts their use, except in the case of a transient cold. The drugs should not be used for chronic conditions like seasonal or persistent allergies, for breathing obstruction caused by a deviated septum or for a common syndrome called vasomotor rhinitis, an innate hypersensitivity to irritants like chemicals, pollutants or cold air.
These afflictions are better treated with nasal steroids, like Rhinocort or Flonase, which build up their action over time to control chronic stuffiness without the risk of rebound or significant side effects.
For more acute problems, oral decongestants like Sudafed that work over a period of hours are a good choice because they lack the potential for rebound congestion. External strips that hold the nostrils open can also help at night.
Many people say they have repeatedly tried to quit using Afrin or Neo-Synephrine without success. Some report that they have broken the habit by discontinuing the spray in one nostril at a time or by progressively diluting the product with saline solution.
Simply stopping cold turkey will usually defuse the rebound cycle in a week or two, Dr. Goldstein said, but a lot of patients cannot resist the urge to spray in the meantime.
"What I do in such cases," he said, "is insist that they stop the nasal spray and put them on a five-day course of an oral steroid like prednisone" that will usually relieve the stuffiness until the rebound is gone.
"I always tell them, 'Don't start the steroids if it's a work week,' " he said. " 'Give me a time when you can get by without getting much sleep' " because of the lingering congestion.
And, sounding like an addiction counselor, Dr. Goldstein adds, "Make sure you throw out every nasal spray decongestant you have, or you won't be able to stop using it."
It is also a good idea to keep the nasal passages moisturized with saline sprays or nasal irrigation devices to help the tissues recover, experts say. Once the worst is over, the physician and the patient must turn their attention to treating the underlying problem, whether through different medications or with surgery to repair a structural abnormality in the nose.
The most obvious way to stay out of trouble is to take seriously the warning on the package label of most decongestants and limit use to three or four days. Some people may get away with using the sprays for a while, but eventually they may find themselves worse off when the rebound sets in.