For a lot of my 20s and early 30s, my mornings went like this: Wake up with a terrible headache, make a big pot of coffee, and chase it with two (or four) over-the-counter pain relievers. If the pain doesn’t go away in a few hours, take four more pills. Repeat as needed. All that ibuprofen and caffeine worked in the short term - but then I’d wake up the next morning with another headache and start over again. This happened at least twice a week, and usually every day during my period, when I’d take even more medicine to manage the cramps. I couldn’t understand why the problem kept getting worse, but then I finally saw a neurologist. “You have medication-overuse headaches,” she said. Translation: Even though the drugs often eased the pain, they were prepping me for my next attack. “For many patients, this starts a vicious cycle,” explains David Dodick, M.D., chairman of the American Migraine Foundation and professor of neurology at the Mayo Clinic in Phoenix. “Before they know it, they’ve fallen into a daily pattern of use.”
The thing is, I’ve always thought of myself as a wimp when it comes to pharmaceuticals. When I was prescribed oxycodone after a surgery, I felt no compulsion to take more than the recommended dose, because I didn’t like how loopy it made me feel. I even made it through 26 hours of labor without an epidural. (Granted, I won’t do that again.) But there’s something so friendly about over-the-counter drugs. They come in cheerfully labeled bottles. They’re stocked next to innocuous household items like lip balm and toothpaste. Somewhere along the way, I stopped treating OTC drugs like medication and mentally reclassified them as something closer to the cup of coffee I needed to function every morning: harmless, comforting, and indispensable.
That view of mine turns out to be common, and problematic. The average American consumer makes 26 trips to stores per year to buy off-the-shelf medications - to treat headaches, insomnia, allergies, and of course, the common cold - compared with just three trips to a doctor’s office, reports the Consumer Healthcare Products Association. That means we’re making a lot of decisions about which medications to take, as well as how much and how often, on our own. Many of us continue to rely on OTC fixes even when those minor ailments may have turned into something more serious. Forty-one percent of adults who report taking a drugstore sleep aid have done so for at least a year, a 2015 Consumer Reports survey showed, even though the recommended limit is two weeks. More than 4 million Americans are overusing OTC pain relievers. Experts say this is a crisis, and it shows no signs of slowing down.
The dangers of self-treatment
Very few over-the-counter drugs can trigger a true physical dependence - one reason they’re safe to be sold without a prescription. “Physical dependence means the drug changes your body’s chemistry in some way so you need more and more of it to achieve the same result, and if you don’t take it, you experience symptoms of withdrawal,” explains Carl Bazil, M.D., a professor of neurology at Columbia University. “These drugs don’t have that kind of impact.” However, it’s possible to become psychologically dependent on OTCs. You can start to believe you need the medicine to find relief, and when you don’t feel better, you take even more. “I’ve seen patients who would take something even if they just woke up feeling a little off in the morning, in an effort to ward off an attack,” Dr. Dodick says. “That’s a slippery slope.” With pain relievers, this can put you at risk for ulcers, gastrointestinal bleeding, liver damage, heart attack, and kidney disease.
After being diagnosed with a chronic pain condition in 2002, Barby Ingle, 45, of San Tan Valley, AZ, was eager to avoid taking an opioid. “I’d heard how addictive opioids can be, so it seemed more responsible to stay away from them,” she says. Barby decided instead to manage her pain with OTC remedies like ibuprofen, acetaminophen, and naproxen. The problem was they didn’t always work. “I started off taking just one pill every six hours. But after a few months, I upped the dose to two pills, then three,” Barby explains. By 2005, she was taking two to four pills every four hours, around the clock. When her doctor later prescribed an anti-inflammatory called Toradol, Barby continued taking the OTCs as well. She started to experience daily stomachaches and noticed blood in her stool. “I thought my pain condition was just getting worse,” she says. “I had no idea it was actually the medication making me even sicker.” Then one morning in January 2007, Barby woke up bleeding, with severe abdominal pain. She rushed to the emergency room, where she was diagnosed with internal bleeding, ulcers, and kidney stones - all caused by the drugs. “They told me if I had waited much longer, I might have died,” she says. Barby spent a week in the hospital and then required another three months of home nursing and physical therapy. Her kidneys have never fully healed.
Pain like Barby’s is not the only thing that leads to overuse. Some patients become dependent on the ritual of taking an over-the-counter medicine - particularly a sleep aid. “Just swallowing the pill becomes this important cue that they rely on to feel sleepy,” Dr. Bazil explains. “And they may also start to associate the woozy feeling you can get from these medications with the process of falling asleep, to the point that it becomes difficult to do so without them.” Amanda, a 41-year-old customer service manager in Beacon, NY, who asked to use her first name only, discovered this a few years ago when her job required monthly overnight shifts that threw off her normal sleep pattern. “I’d sleep all day after a night shift, and then be wide awake at bedtime. I was always exhausted when I got back onto day shifts the next week,” she says. “A coworker used an OTC sleep aid, so I decided to try it.”
Amanda was careful to take only the recommended dose of two caplets in a 24-hour period. At first, it helped, but after a few months, her insomnia got worse. She struggled to sleep even during weeks when she didn’t work night shifts. “I started taking it more often to fall asleep,” Amanda says. “I’d take it if I woke up in the middle of the night and my mind was racing. I’d take it if I had a bad day and didn’t want to deal with what I was feeling.” This went on for almost two years; at the height of her dependency, Amanda estimates that she was taking four to eight caplets a night, three or four nights a week. On days after eight-pill nights, she could barely get out of bed. The cycle didn’t stop until she changed jobs - and, more important, told a doctor what she was doing.
Amanda realizes now that the insomnia was a symptom of chronic anxiety and depression, which were eventually managed with far more effective mood stabilizers. Insomnia is a hallmark of both conditions - in fact, Dr. Bazil urges anyone struggling to fall or stay asleep to be evaluated. “If that’s what’s really going on, it doesn’t matter how much of an OTC you take,” he says. “If you don’t address the underlying problem, you’ll never get better.” This might be the scariest thing about over-the-counter drug overuse: It can distract you from dealing with a much bigger, and potentially more dangerous, condition.
Protecting yourself and others
So why is it so easy to fall into the OTC-overuse trap? Misconceptions about how the drugs work may play a role: “Consumers sometimes think that if they take a higher dose, they’ll get relief more quickly,” notes Ed Kuffner, M.D., chief medical officer at Johnson & Johnson Inc., which owns many OTC brands, including Tylenol and Benadryl. “In fact, you won’t feel better any faster and it can lead to serious illness or injury.” The pharmaceutical industry follows strict rules around safety labeling. Every over-the-counter drug comes with a list of side effects, as well as directions on dosage, frequency, and when to see your doctor. And companies are constantly working on ways to further catch your eye, Dr. Kuffner says - printing reminders on bottle caps to check the active ingredient on the label, for example, so consumers won’t inadvertently take two medications containing the same pain reliever. “The Drug Facts label is there for a reason,” says Anita Brikman, executive director of the Consumer Healthcare Products Association Educational Foundation, a nonprofit that sponsors the industry’s consumer education website, knowyourotcs.org. “It’s very important that the consumer read it and follow the instructions closely. The OTC industry believes in responsible self-care.”
It’s the “responsible” part that can be surprisingly tricky. The symptoms treated by OTC medications are annoying but often not life-threatening, and in the crush of work and family, it can be tough to see a doctor. Still, that’s often exactly what it takes to find lasting relief - yet another reason that affordable health care is so essential. “When people are facing high co-pays and deductibles, they increasingly settle for less optimal care,” says Eliot Fishman, senior director of health policy for Families USA, a nonpartisan nonprofit organization in Washington, DC, that advocates for consumers. One in four adults with non-group health insurance say they’ve gone without care because they couldn’t afford it - and more than half of those skipping treatment did so because their prescriptions were too expensive. Uninsured people are even less likely to see a doctor, an alarming fact given that attempts to repeal the Affordable Care Act could result in at least 20 million more Americans going without coverage, according to the Congressional Budget Office.
Those of us who are fortunate enough to see a doctor may need to guide the appointment. Dr. Bazil points to research showing that general practitioners are unlikely to discuss sleep issues with their patients or offer much beyond a prescription or OTC drug when a patient brings it up: “Doctors are pressed for time, and it’s easier to just say, ‘Take this pill.’” While in most cases it’s perfectly fine to treat sleep troubles or a runny nose with something over-the-counter, it’s important that the conversation doesn’t end there. Gayle Thompson, a 45-year-old journalist in Nashville, was told to take an OTC antihistamine every few nights to help her sleep during pregnancy. After her baby was born, she switched back to a prescription sleep aid. “But I’ll still take an antihistamine on nights when I know I really need to sleep,” she says. “I don’t think my doctor even knows.” You should tell your M.D. what you’re taking and how much, so she can monitor the mix for potential interactions, side effects, and dosing issues, Dr. Kuffner says. Barby’s near-death experience was a wake-up call for her and her doctor: “It wasn’t until I landed in the hospital that he realized how long I’d been taking the pain relievers,” she says. “I hadn’t communicated all my symptoms, either - now I know to be a better advocate for myself.”
Once I began working with a neurologist, it became clear that I was actually undertreating my headaches, which were really chronic migraines. Botox injections four times a year have taken my headache frequency down from twice a week to once every three months, but at a steep price. Even with private insurance, my co-pay for these injections runs up to $400 per round - way more than the 10 bucks I spent each month on ibuprofen. So here’s something else you can do: “Ask your representatives what they plan to do about rising prescription drug costs,” suggests Fishman. Find yours at usa.gov/elected-officials.
Ultimately, though, smarter OTC drug use requires a shift in mindset. It’s about remembering that even though they’re sold next to gum and dental floss, OTC medications are still medications. It’s about prioritizing our own health care by taking the time to make our own doctor’s appointments (not just the kids’!), talking through new symptoms and concerns, and speaking up when we’re not finding relief. “It’s crazy to think what we do to ourselves without paying attention,” Amanda says. “And how much we’re willing to endure before we say, hey, maybe this isn’t OK.”
When to call the doctor
So how do you know if your symptoms can be fixed with a quick trip to the pharmacy - or if you need proper medical attention? If any of these signs are true for you, it’s time to make an appointment.
• You’ve been taking an OTC sleep aid several times a week for two weeks.
• You have trouble falling or staying asleep when you don’t take it. • The idea of “bedtime” makes you anxious.
• You frequently wake up in the middle of the night with your mind racing, and you can’t fall back asleep.
• You’re struggling with feelings of sadness, malaise, or anxiety during the day as well.
• You’re taking an OTC pain reliever twice a week (or even just once a week, but continuously for a period of three months).
• Whenever you take an OTC pain reliever, you have to take a second dose for the same attack, or take it again the next day when the pain returns.
• You take OTC pain relievers at higher-than-recommended doses - and you still barely get relief, if you get any at all.
• You’ve been using a nasal spray or antihistamine pill for more than a few weeks, without much relief.
• Your mucus is green or yellow, which could signal a cold or infection.
• You also have a cough or are having trouble breathing, symptoms of allergic asthma. “An allergist can help pinpoint your triggers and get you more effective treatment,” says Clifford Bassett, M.D., medical director at Allergy and Asthma Care of New York, who is also on the faculties of the NYU and Weill Cornell medical schools.
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