Extensive research has been done on the use of a variety of medications to treat back pain and the findings are, the put it bluntly, all over the place. We have reviewed each class separately to minimize confusion and do our best to come to useful conclusions. NSAIDs (ORAL) - GOOD EVIDENCE We reviewed three high-quality meta-analysis studies (1, 2, 3) on the use of oral NSAIDs. One concluded the evidence supporting the use of oral NSAIDs was low for back pain (1). The second, a larger meta-analysis review of 65 studies, concluded the evidence was good for the use of oral NSAIDs for short-term pain relief in acute and chronic low-back pain without sciatica (2). However, effect sizes were small. Lastly, the third was a Cochrane Review that concluded NSAIDs are more effective than placebo, but once again the effect sizes were small (3). These studies also cautioned against long-term use of these drugs due to an increase in the risk of adverse events commonly associated with oral NSAIDs. A fourth study reviewing a plethora of approaches to low back pain (4), reviewed the same studies and concluded, due to the side effect potential, NSAID use should be low-dose and only used for a short time. We did not find this to be compelling support for the use or oral NSAIDs with acute or chronic low back pain, especially when factoring in potential adverse side-effects. NSAIDs (TOPICAL) - POOR While there is support for topical NSAIDs with single joint osteoarthritis (see our knee review for references) and acute strains and sprain injuries (6), the evidence is much lower for acute or chronic low back pain. A 2010 study reviewed the Medline and Cochrane CENTRAL databases and came to the conclusion "the current evidence does not support the use of topical NSAIDs in acute and chronic low back pain."(5) ACETAMINOPHEN - FAIR(+) EVIDENCE A meta-analysis reviewing the effects of acetaminophen on reducing low back pain found acetaminophen to have good evidence (7). However, a systematic review in The Lancet (8), concluded the use of paracetmol (acetaminophen) did not affect recovery time compared with placebo groups for low back pain. NOTE: A 2008 Review (12) by Chou et al in a review for the American Pain Society/American College of Physicians clinical practice guideline found "good evidence" supporting the use of oral NSAIDs and acetaminophen for low back pain. MENTHOL CREAM - FAIR(-) EVIDENCE A 2017 review of clinical studies on "topical menthol" or "biofreeze" found both a statistical and clincially significant pain reduction in studies of the hand, neck, and back. Results were mixed for muscle soreness. Individuals with knee pain had statistically significant reduction in knee pain, but did not meet the criteria for clinical significance (9). NOTE: This study was sponsored by Performance Health Research, the manufacturer of Biofreeze. CAPSAICIN CREAMS - FAIR9(-) EVIDENCE A study comparing the efficacy of topical NSAIDs with topical capsaicin for pain relief in osteoarthritis concluded they were both effective at licensed doses (10). Another study by Chrubasik et al (11), comparied capsaicin topical treatment to a placebo group, after 3-weeks of treatment the median pain score had decreased by 49% (capsaicin group) and 23% (placebo group.) There were more adverse events in the capsaicin group, but it was generally well tolerated. The results indicated that capsaicin cream is potentially useful to patients with chronic soft tissue pain. IMPORTANT NOTE: Once again, we highly recommend consulting with a physician before trying medication(s).It is difficult to determine which medication is the best choice due to the balance of benefits and risks, as well as the personal cost considerations for each patient. The available evidence does not clearly indicate which medication offers the overall most beneficial outcome. It is important to take into account an individual's specific priorities and preferences when considering the potential benefits, harms, and costs of various medications.