George Resch, who goes by TankSinatra on social media, recently mentioned that he had an addiction to the over-the-counter nasal spray Afrin. “I have been congested for a year,” he said on the podcast Meme Daddies.
How does that happen? Plenty of over-the-counter medications — those that are sold on pharmacy and grocery store shelves without a prescription — have the potential to be habit-forming if used incorrectly.
OTC medications are available for dozens of conditions, including allergies, cough, diarrhea, constipation, skin issues, and pain. As long as you use them for short periods of time and as directed, you should be fine. Go outside those label instructions, though, and you could be inviting trouble.
You could end up with something called a rebound effect, which is when the original symptoms you were trying to treat come back, sometimes with a vengeance, after you stop taking the drug.
What is the difference between misuse, dependency, and addiction?
A rebound effect, which generally comes from medication misuse, is not the same as a true addiction, although there are nonprescription drugs that can be abused or contribute to an addiction relapse.
A person who is misusing an OTC drug can develop a physical dependency on the drug, which means their body comes to rely on it for a particular function. That isn’t the same as an addiction to a drug, which results in compulsive behavior to get the drug despite the sometimes devastating and even life-threatening repercussions.
Addiction can happen with fentanyl, oxycodone, or illicit drugs like cocaine or heroin. Typically the person who has the addiction needs more and more of the substance to get the same high or other effects. That person keeps misusing a substance despite experiencing negative social, physical, and psychological consequences associated with the abuse, Dr. Kelly Johnson-Arbor, a medical toxicologist and interim executive director of the National Capital Poison Center, explained.
Rather than using substances for a high or to feel better, misuse means that people take a drug to treat a condition or symptoms but do so incorrectly.
“Misuse occurs when a person takes more of the medication than prescribed on the label, for a longer period of time, more often than what is recommended, or is using it for a purpose other than what was intended,” explained Pat Aussem, associate vice president of consumer clinical content development at the Partnership to End Addiction.
That said, the physical consequences of misusing an OTC drug can be unpleasant and can include withdrawal or rebound symptoms. And misuse can lead to addiction when it comes to certain classes of medications, Johnson-Arbor explained.
Here’s what to know before you start taking any OTC medication.
Nasal sprays with oxymetazoline
The nasal decongestant Afrin contains oxymetazoline, which reduces congestion by narrowing blood vessels in the nose. But using it too often can backfire, leading to “Afrin addiction,” as many people have posted about on TikTok. (The hashtag #AfrinAddiction has nearly 800,000 views on the platform.)
“When Afrin is used for longer than three days, it can cause a chemical imbalance in the body that actually results in worsening nasal stuffiness when Afrin is discontinued,” Johnson-Arbor said. This leads to a vicious cycle of using Afrin to relieve decongestion, then using it again when the congestion returns. The medical name for the condition is rhinitis medicamentosa.
In addition to nasal stuffiness, congestion, and pain, overuse of Afrin can lower blood pressure and heart rate, leading to dizziness or fainting. Doctors sometimes prescribe steroids to lessen the discomfort of quitting Afrin, Johnson-Arbor said.
You should not use Afrin and other nasal sprays that contain oxymetazoline for longer than three days.
Just about any medication you can take for head pain — aspirin, ibuprofen, naproxen, acetaminophen, or anything else — can cause rebound headaches if you take them for prolonged periods of time.
A rebound headache, also known as a medication overuse headache, may be a possibility for anyone who is taking pain relievers for at least three months and then starts having headaches 15 or more days per month.
So how often is too often when it comes to pain relievers? Well, it depends on the drug, but if you are taking an nonsteroidal anti-inflammatory drug at least 10 times a month, you could be at risk for medication overuse headaches.
The headaches generally start first thing in the morning and will temporarily get better after you take the drug, but then the pain comes back. Other symptoms can include nausea, irritability, and neck pain.
The best approach is to limit how often you take pain relievers. “If someone has to take one of these more than two to three times per week (or more than 10 to 15 times in a month), they are putting themselves at significant risk of developing the medication overuse headache,” said Kayode Giwa, a pharmacist and clinical specialist in psychiatry and internal medicine at Houston Methodist.
The antidote is typically taking a vacation from the medications for one or two weeks so our bodies can reset, he added. If you’ve been using these medications for long periods of time, taper off instead of going “cold turkey,” Johnson-Arbor said.
Eye drops that contain tetrahydrozoline
Some eye drops are marketed as a way to reduce eye redness along with itching and dryness. The most well known is Visine, which is similar to Afrin in the way it works. The eye drops contain the decongestant tetrahydrozoline, which works by constricting blood vessels in your eye.
While this may be an effective temporary solution, over the long term it can exacerbate the problem, ending up in a vicious cycle. When the redness wears off, your eyes may appear even more red (“rebound redness”), leading to more eye drops, more red eyes, more eye drops, etc.
Ophthalmologists typically recommend using artificial tears rather than products that claim they’ll take the red out. If you do use products containing decongestants, limit them to occasional use and not for longer than 72 hours, the American Academy of Ophthalmology warns.
Just know that some artificial tears products were recently recalled due to bacterial contamination. While those particular brands are no longer being sold, check the label for any products you might have at home. (The brand names are EzriCare or Delsam Pharma’s Artificial Tears.) Three people who have used the drops have died from serious infections; in some cases, people have had permanent vision loss or the need for eye removal.
In addition to using drugs for the correct amount of time, you should also not use them on any part of the body other than those recommended by the manufacturer.
Unfortunately, a “prank” portrayed in the 2005 film Wedding Crashers suggested that putting eye drops in a drink can cause violent diarrhea or other side effects. In fact, consuming tetrahydrozoline can be fatal and was even implicated in one homicide case. The perpetrator allegedly added the drops to her husband’s drinking water for three days.
“This is a super dangerous thing to do,” Giwa said.
Skin creams that contain hydrocortisone
OTC cortisone cream contains the active ingredient hydrocortisone, which is a corticosteroid that blocks inflammation-causing immune reactions. It’s commonly used to treat rashes, sunburns, eczema, and other skin conditions.
It’s remarkably effective at reducing symptoms like itching. However, the medication, especially the stronger formulations, can lead to “red skin syndrome,” a sort of withdrawal process marked by bright red skin along with burning, stinging, itching, and pain. These typically occur within days of ceasing use of the product, Johnson-Arbor said.
Many cases of red skin syndrome occur after long-term use of hydrocortisone (a year or so). The National Eczema Association cautions against using topical corticosteroids for more than two to four weeks. After that, frequency of use should be tapered off.
Using corticosteroids on the skin for too long can lead to skin thinning and permanent stretch marks. When used on the eyelids frequently and for a prolonged period of time, it can also increase the risk of glaucoma and cataracts.
There are no ingredients in ChapStick and other lip balms that could cause physical dependence, but overuse may lead to what’s known as a “behavioral addiction.” People have admitted to putting tube to lip as often as 300 times a day and needing to have multiple tubes with them at all times. There’s even a Facebook group, Lip Balm Addicts Anonymous, “For everybody addicted to flavoured wax.”
As far as habits go, though, this is one of the least harmful. The main consequence is likely to be drier lips. That’s because many people like to lick the balm off, allowing digestive enzymes to dry out the membranes.
Ingredients like phenol, menthol, and salicylic acid may also dry out your lips, causing you to use yet more of the product. If you use lip balm, stay away from these ingredients and avoid flavors that invite licking.
Laxatives with bisacodyl, senna, or castor oil
Although there are several different classes of laxatives, problems related to misuse are more likely with stimulant laxatives containing bisacodyl (brand name Dulcolax), senna, or castor oil.
“They basically make your large intestine act more. They push more stool out of your body,” Giwa said.
Misuse is not uncommon among people with eating disorders because of the misperception that they cause weight loss. In fact, they don't, they generally just lead to temporary water loss, he said.
To be safe, don’t use these products for more than three to five days. “The body becomes physiologically addicted so you can only have a bowel movement when you use them. After many months or years, your colon stops working,” Giwa said. “If you need it more than that, you need to see a physician,” he said.
Fiber-containing or bulk-forming laxatives are considered safer ways to get things going if you have a problem with constipation.
Nasal inhalers that contain propylhexedrine
Benzedrex is a nasal decongestant that comes in an inhaler (rather than a spray) that has the potential for misuse and abuse.
“OTC inhalers like Benzedrex can be used to simulate stimulants,” Aussem said.
The key ingredient is propylhexedrine, which sometimes people take specifically for the stimulant effect. Abusing the drug can cause high blood pressure, abnormal heart rhythm, paranoia, and even death.
Because of the stimulant effect, people who already have substance use disorders can be particularly vulnerable. “I was working with a family where a loved one had a stimulant use disorder as a result of using meth,” Aussem said. “After attending residential treatment, he was trying to avoid using meth and instead bought Benzedrex.”
The Food and Drug Administration warns against more than two inhalations in each nostril every two hours. You also shouldn’t use it for longer than three days.
Cough drugs with dextromethorphan (DXM)
The active ingredient in many extra-strength cough suppressants, including some formulations of Robitussin and NyQuil, dextromethorphan may be one of the more potent compounds out there in terms of abuse or misuse.
According to the Drug Enforcement Administration, more than 100 medicines contain DXM. “It’s the number one decongestant we have,” Giwa said.
“Referred to as Robo-tripping, DXM used in cough syrup can be used to get high,” Aussem said. Some people also refer to it as “skittling.” At extremely high doses, it can cause hallucinations. “There have been cases where people have had to be psychiatrically hospitalized,” Giwa said. “It also doesn’t show up on drug screens.”
Antidiarrheal drugs that contain loperamide
Misuse of antidiarrheals containing loperamide (for example, Imodium) is becoming more widespread. “In the last few decades, there have been increased reports of loperamide abuse and misuse reported to Poison Control Centers nationwide,” Johnson-Arbor said.
Loperamide is taken to achieve euphoria but also to self-treat opioid withdrawal, Aussem said.
Unfortunately, it can also cause nausea, constipation, sleepiness, and stomach pain.
The FDA has warned of potentially fatal heart problems with higher-than-recommended doses of the drug, especially when combined with certain other drugs such as Tagamet (cimetidine) and Zantac (ranitidine).
“Since loperamide acts like an opioid in overdose situations, naloxone (Narcan) may be effective in reversing breathing abnormalities that occur after loperamide overdose,” Johnson-Arbor said.
The FDA approved the first over-the-counter naloxone spray on March 29.
Antihistamines that contain diphenhydramine
When taken in doses higher than recommended, the active ingredient in Benadryl, diphenhydramine, an antihistamine, can have intoxicating effects, sometimes making people experience euphoria, delusions, or hallucinations.
Although not as habit-forming as pseudoephedrine in decongestants (see below), diphenhydramine is also prone to misuse or abuse. One example was the “Sleepy Time Chicken” trend on TikTok in 2022. This involved some people reportedly basting chicken in antihistamines and then eating it. “It produced a downer, stoner feeling,” Giwa said.
The FDA posted a warning about the practice, noting that boiling medications can make them more concentrated and release vapors that may damage your lungs. Long-term use can cause severe constipation, blurry vision, and dry mouth.
In 2021, the FDA issued a warning about the “Benadryl Challenge,” which included some people taking diphenhydramine in an effort to hallucinate.
In general, using any antihistamine over the long term has the potential to cause withdrawal symptoms when stopping, Giwa said. The most common offenders, though, are cetirizine (Zyrtec) and levocetirizine (Xyzal), he noted. Both can involve unbearable itching, Johnson-Arbor said.
Decongestants with pseudoephedrine
In many states, some decongestants, including certain formulations of Sudafed or DayQuil, are only sold “behind the counter” and you have to be 18 to buy them. The key ingredient is pseudoephedrine, which has the opposite effect of antihistamines. “People will abuse it for weight loss because they are so stimulating,” Giwa said. “They’re very comparable to your classic stimulants like Ritalin, cocaine, Adderall, and meth. You can become dependent.”
Many OTC products actually contain both decongestants and antihistamines, which is a lot like mixing vodka and Red Bull, Giwa said.
“It’s a similar feeling to where your heart is racing really fast but you’re drowsy from the alcohol [or antihistamine],” he explained. “It’s an upper and a downer. Physiologically you're down but you’re not going to fall asleep.” People will sometimes use these OTC products in combination with an illegal drug to calm themselves down, he added.
What to do
If you experience itchy skin from antihistamine withdrawal, or any other unexpected symptoms when you stop taking an OTC medication, contact your doctor. Also get in touch with a healthcare professional if you’re unsure how to take a medication, especially how long to use it.
If unwanted signs or symptoms develop after use or misuse of over-the-counter medications, contact Poison Control for immediate guidance. There are two ways to contact Poison Control in the United States: online at www.poison.org or by phone at 1-800-222-1222. Both options are free, confidential, and available 24 hours a day.