It can also cause permanently enlarged turbinates with chronic use.
Look, there are always extreme cases. Just look up how many people need a liver transplant or even die each year from misusing paracetamol. So should we make it a prescription drug? Maybe, I don't know, it's always a trade-off.
I've never taken any opiod, but two weeks of being unable to breathe properly or sleep sounds as hellish as my idea of quitting heroin.
I mean, I quit smoking, hardest thing I've ever done, and the physical withdrawal effects were insignificant compared to that.
It's funny; looking back, I quit smoking exactly BECAUSE I was suffering from crazy congestion, and after a week of Afrin and poor sleep I thought quitting smoking altogether would help me regain my sanity.
Let me assure you that there's (yet?) no Xylometazoline epidemic ravaging though Europe, with tens of thousands of people dying each year, destroying families and communities, in effect causing endless grief for people and huge profits for pharma companies. There's also no black market for Xylometazoline, with people overdosing because there's nasal spray on the street that is contaminated with a much more potent derivative than can kill pretty much instantly. I've also never heard of babies born with congested noses that spend their first weeks of life going through a Xylometazoline withdrawal.
So to summarize, I think my initial statement that a physical dependence on Xylometazoline is less harmful than a dependence on opioids is probably correct.
The strategy I’ve heard is purchasing a normal bottle, and refilling it with boiled cool water when it’s ½ empty. Then refilling it again when it’s ¾ empty.
Xylometazoline is an absolute godsend, and has even more efficacy in a dual-action spray with saline water.
It feels nothing short of magical to do one spray per nostril, and be completely uncontested in less than 10 minutes.
It also creates dependency. A drug that is ineffective cannot cause dependency.
Many people have used decongestants so much they cannot quit them or will have to suffer weeks of nasal congestion. I risked going through that; later I swore I will never touch one ever again.
Very tangentially, "iatrogenic" is a nice niche vocabulary word: Something unintentionally caused by a medical activity, usually undesirable.
My wife has one kidney and as such is told to avoid NSAIDs as a class of medicine. She’s realistically fine taking it every so often but her doctors are asking her to avoid using kidney capacity that could hypothetically be needed to filter and excrete something else.
Acetaminophen/Paracetamol is great alternative for her since it’s processed in the liver. However if you’re a frequent drinker, have a liver deficiency, or have to take some other drug straining your liver, it’s contraindicated.
For most of us most of the time you’re completely correct though.
In the case of these nasal spray decongestants I had a case of rebound congestion due to over-reliance on them while surviving some family bringing really bad colds into the house and my son starting daycare. It was really bad. I then managed by switching to an alternating schedule of pseudoephedrine and the nasal spray so I could reduce the physical dependency on the latter and get a good night’s sleep.
My doctor eventually cleared me to take an allergy spray medication (Fluticasone propionate) that is safer for long term use but generally not used for colds because it inhibits immune response and mask the symptoms which can cause new infections and hurt your ability to heal. Yet another case of the mundane medicine that is contraindicated. While seemingly being the wrong thing to be put on while fighting off infections it worked out great.
After four months I had seen enough child germs and no adult has brought their own plague or food poisoning (it was a very bad summer for me) and I finally became healthy again.
What many people don't know: Overdosing on paracetamol is the leading cause of acute liver failure. It's also contraindicated for people with Gilbert's syndrome, which is actually pretty common (~5% of people in the US) and most people don't even know they have it, as it's harmless and usually only found accidentally through high bilirubin levels in the blood.
If there was a way to somehow sum up all of the suffering caused by these sprays from dependency (which lasts weeks, months, years even) and compare that with the suffering alleviated from a cold (which lasts a fews days), my bet is these cause more harm than good.
It's actually slightly more selective for a1 receptors than the German alternative. They both have the same dependence potential and rebound liability.
EDIT: After looking a bit more, the simple answer seems to be that it's not FDA approved for nasal congestion, and since there's not much money to be made, there's simply no incentive to go through the costly approval process..