Effective doctor-recommended OTC strategies for managing chronic stable back pain. Second-line options include topical analgesics like capsaicin cream or diclofenac gel and temporary relief from lidocaine patches. Learn about adjunctive therapies like TENS, ultrasound, or laser therapy to enhance functionality and reduce pain intensity.
January 9, 2025

Lower Back Pain: 3 Lines of Treatment

Evidence-Based Over-The-Counter Guide

William Shen

William Shen

Co-founder & CPO

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Chronic stable back pain without any recent trauma or changes in symptoms can be treated with conservative management and over-the-counter pain management.

First-line recommendations: 

  • Nonsteroidal Anti-inflammatory Drugs (NSAIDs): Ibuprofen 200-400 mg every 6-8 hours as needed, or naproxen 220 mg twice daily. 220 mg naproxen sodium (FDA N020267).

  • Acetaminophen: For mild-to-moderate pain or when NSAIDs are contraindicated. Dose: 500-1000 mg every 6-8 hours as needed. 650mg extended-release acetaminophen (FDA M013).

Second-line recommendations:

  • Topical analgesics: Capsaicin cream or diclofenac gel applied to the affected area 3-4 times daily for localized relief. 1% diclofenac gel (FDA M017). Should be used for <3 months at a time. Camphor may also be effective. FDA-approved combination analgesic (FDA M017).

  • Lidocaine patches: when back pain is particularly debilitating, lidocaine (a surgical grade nerve-numbing agent) can be used to offer temporary relief. Not for daily use. 4% lidocaine patches (FDA M017).

Adjunctive recommendations per 2017 ACP guidelines:

  • Transcutaneous Electrical Nerve Stimulation (TENS): A non-invasive therapy that uses low-voltage electrical currents to reduce pain perception by stimulating sensory nerves. Sessions typically last 30-60 minutes and can be performed at home or in clinical settings. Studies suggest it may reduce pain intensity and improve functionality for certain patients. FDA-cleared TENS Unit (FDA 510(k) K092546).

  • Therapeutic ultrasound and laser therapy may also be effective. Ask your doctor.

Citations:

North American Spine Society: Diagnosis and Treatment of Low Back Pain (updated 1/27/2021). 

Ageing and Health, Guidelines Review Committee, Maternal, Newborn, Child & Adolescent Health & Ageing (MCA). WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. World Health Organization; 2023

What OTC evidence is reviewed?

  • For each condition, we performed a literature review to find a recent widely cited expert group guideline published in the leading specialty-specific peer-reviewed journal or top general medical journal.

  • Based on the recommendations in the publication, we identify recommended active ingredients and devices that are available over-the-counter per FDA regulations.

What evidence is prioritized?

Levels of evidence considered:

  • Tier 1 (Safe and Definitely Effective): Professional field consensus or multiple randomized controlled clinical trials showing the same conclusion. Wherever possible, we use Tier 1 evidence for "first-line" recommendations.

  • Tier 2 (Safe and Probably Effective): Individual clinical trials which may be discordant or large-scale observational experience. Tier 2 evidence may inform "first-line", "second-line", or "supplement" recommendations.

  • Tier 3 (Safe and Maybe Effective): Mechanistic plausibility without high-quality clinical evidence of efficacy but high-quality evidence of safety. Tier 3 evidence may inform "second-line" or "supplement" recommendations.

How does MDandMe select recommended products?

  • Based on the top clinical recommendation, we evaluate products containing the recommended active agent with FDA-approved dosage based on price, average customer reviews, how often it is purchased, and how quickly it will ship to home. 

  • We provide public documentation of the active ingredients in our recommendations, using all 32 FDA monographs, Prescription-to-Nonprescription (Rx-to-OTC) Switches, as well as New Drug Application (NDA) approvals.

How does MDandMe select recommended devices?

  • Based on the top clinical recommendation, we evaluate devices that are FDA-cleared or comply with other medical guidelines (if not a FDA-regulated category) by reputability, price, and average customer reviews.

  • We provide public documentation of supporting evidence for each device.  

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