Medically reviewed by, Russell Braun RPH
The pain is getting to the point where it is all you can think about. It’s getting hard to concentrate on things you enjoy or even relax and watch television. You hate going to the doctor, but need a solution and fast. If this sounds like you then finding the strongest OTC pain reliever is a must!
The only problem is once you walk in the pharmacy you will see a whole row of pain relievers. All with flashy marketing on the bottle and phrases that make them sound too good to be true. So which one should you pick?
In general treating pain needs to be something you discuss with your doctor. You want to make sure it is not something serious and figure out how to treat the cause of the pain. However, many types of pain can be made tolerable with self treatment using OTC pain relievers. Examples of pain commonly treated with OTC medication include:
|Back pain||Dental pain||Gout flares|
1. The Good News About OTC Pain Relievers
Most people report that OTC pain relievers work. Which is good since it is estimated that in 2019 people spent almost 2 billion dollars on them!
Each kind of pain medicine has benefits and risks. Some types of pain respond better to one kind of medicine than to another kind. What takes away your pain might not work for someone else, or vise versa.
A final piece of good news is that OTC pain relievers are not habit forming like many prescription options can be. Also, the risk of addiction is also lower than with prescription pain relievers like opioids.
2. What Is The Most Powerful Over The Counter Pain Killer?
There is not a direct comparison of how strong one OTC pain reliever is compared to another one. What you person may find relief from may not help another person as much. The reason for that is that all the oral OTC pain relievers work on a similar process in the body. However, in slightly different ways.
How Do OTC Pain Relievers Work?
It starts with something called arachidonic acid that is present in the body. When there is an injury or the immune system sense damage that need repaired arachidonic acid gets the nod. Then enzymes called cyclooxygenase (COX) go to work. They convert the arachidonic acid into substances that help the body respond to the injury. These substances are thromboxanes, prostaglandins and prostacyclins.
Cyclooxygenase (COX-1 and COX-2)
Once these three key substances are formed they get to work doing the following functions.
|Thromboxanes||Cause platelets to stick together creating a blood clots.|
|Prostaglandins||Cause blood vessels to dilate or relax, letting more blood into the area. They also increase the temperature of the body in the hypothalamus located in the brain. Finally, they play a role in pain perception.|
|Prostacyclins||Cause blood vessels to dilate or relax, letting more blood into the area.|
NSAIDs are OTC pain relievers that block the COX-1 and COX-2 enzymes. NSAID stands for non steroidal anti-inflammatory drug. They were given this name because they are not structurally similar to steroids but have many of the same effects. Especially, when it comes to fighting inflammation.
By blocking the COX enzymes they are able to reduce pain by stopping the formation of all three chemicals. Although the majority of the benefits are tied to reducing levels of prostaglandins.
What Are NSAIDs Used For?
NSAIDs are the most common OTC pain reliever found on pharmacy shelves. They are used for the following issues:
- Reduce swelling from inflammation
NSAIDs work quickly, usually within 30 minutes of taking a dose. However, they do not last all day. Therefore, most will need to be taken multiple times per day to continue pain relief. When used for a short duration (3 days or less) there are few side effects.
Not All NSAIDs Are The Same
NSAIDs are broken into five groups based on their chemical structure. If you don’t get relief from any one class then one of the drugs in the other NSAID class may help your pain. However, only two different classes of NSAIDs are for sale OTC. The table below lists these types of NSAIDs classes.
|NSAID Class||Example Drugs|
|Propionic acids||Naproxen (Aleve, Naprosyn, Anaprox)|
Ibuprofen (Motrin, Advil)
The three other classes of NSAID’s are available only via prescription. Therefore, you would have to see your doctor to get one of these medications. If the OTC varieties don’t work this is probably a good next step to try and find relief from your pain. In addition, higher strengths of some OTC NSAIDs are prescription only.
Prescription only NSAIDs are listed in the table below.
|Ketoprofen (Orudis)||Flurbiprofen (Ansaid)|
|Ketorolac (Toradol)||Fenoprofen (Nalfon)|
|Diflunisal (Dolobid)||Tolmentin (Tolectin)|
|Meclofenamate (Meclomen)||Mefenamic acid (Ponstel)|
|Meloxicam (Mobic)||Piroxicam (Feldene)|
COX-1 vs COX-2
When taken for short durations, NSAIDs are typically safe for most people. However, extended use for 10 days or more can lead to side effects. Most notably problems with the stomach and kidneys are the issue. These side effects can be tied back to the fact that COX-1 is found in large amounts in these areas of the body.
COX-2 is typically only found when there is inflammation present. Therefore, it would be great to be able to block COX-2 and leave COX-1 alone to lessen the risk of side effects. Which is why COX-2 selective NSAIDs were created.
Today there is only one COX-2 selective NSAID still available in the U.S. The other versions were taken off the market due to concerns around heart failure. COX-2’s are prescription only medications. If you will need to be on NSAID’s for long periods it may make sense to ask your doctor about this option.
Acetaminophen is another very widely used OTC pain reliever. It is the first line treatment for osteoarthritis pain according to the American College of Rheumatology. The key benefit is the risk of adverse effects is lower than that of NSAIDs. That is good news because many patients need to use OTC pain relievers for long periods of time.
What Is Acetaminophen Used For?
Similar to NSAIDs, acetaminophen is used for the following:
It is important to note that it is not used to reduce inflammation. That has to do with how it works. Acetaminophen blocks the action of prostaglandins however it only seems to act in the central nervous system. That is why it won’t block inflammation in other parts of the body.
3. What Is The Strongest Over The Counter Painkiller For Back Pain?
Back pain can be very hard to deal with. This is because your spine is the system that holds your body up when standing and walking. It also can make it difficult to lay down and rest if your having back pain. Getting relief is a must to be able to function and thrive.
For short term back pain from a muscle pull or sprain, NSAIDs are probably first choice to help decrease the swelling. If the pain if more chronic or long term then acetaminophen is a better choice. Long term exposure to NSAID’s puts you at risk of side effects.
Back pain is also a great candidate for topical pain relievers as well. Lidocaine patches to numb the sore areas are a great way to help people get good sleep. Sleep is key to repairing and healing the body (which is what the inflammation is trying to do)
Another secret weapon for back pain are creams, ointments or gels that you can rub into the affected areas. There are several different ways these products work to relieve pain which means more likelihood of comfort by combining them. Topical pain reliever options include:
- Examples: Voltaren gel, Trolamine salicylate
- Example: Menthol, Camphor
- Example: Capsaicin cream & ointment
4. What Is The Safest Over The Counter Pain Reliever?
Most OTC pain relievers are relatively safe, otherwise they would not be allowed to be sold without a prescription. However do not fool yourself into thinking that all these medications are completely harmless either. Two major factors come into play for the safety of OTC medications.
The dose you take can be the difference in pain relief and ongoing, nagging pain. Generally speaking taking a high enough dose to get the pain under control and then using a lower dose to maintain the pain is a best practice.
An example would be taking 200mg of ibuprofen so you can sleep through the night due to hip pain. That dose is not likely to be high enough to last until you wake up. You may want to take 400mg or 600mg instead.
With dose you want to make sure you don’t exceed daily maximums. These are listed in the table below for your reference. Talk to your doctor about what is the right dose for you.
|Drug||Maximum Daily Dose|
|Acetaminophen||4,000mg / day if under 65|
3,000mg / day if over 65
|Ibuprofen||3,200mg / day|
|Naproxen||1,500mg / day|
|Diclofenac||150mg / day|
|Aspirin||4,000mg / day|
Watch out for combination products! This is especially true for acetaminophen which finds its way into many OTC and prescription medications. Read the labels make sure you are not taking more than one drug that has acetaminophen in it.
Typically acetaminophen is the safest OTC option but if the dose is too high it can be toxic to the liver.
Long term use of NSAIDs on a daily basis can have side effects. One major concern is stomach ulcers and bleeding risk. In addition the Food and Drug Administration (FDA) has issued a warning for increased risk of heart attack and stroke with extended use. Don’t taken these medications for longer than you really need to. Remember other options exist such as topical medications and lifestyle modifications, click here for some examples of these.
Acetaminophen is the safer option if ongoing treatment is required. It does not have the risk of ulcers, bleeding or heart attack and stroke. The key thing to remember with acetaminophen is not to take too much per day. Otherwise your liver can get depleted on glutathione, which helps it metabolize acetaminophen.
5. What Is The Best Natural Pain Killer?
There are many dietary supplements on the market that claim to help with pain relief. Unfortunately, there is often not much clinical evidence to support many of these claims.
Another concern is knowing how reliable the manufacturer of the product is. Does the product actually have as much of the active ingredient as it claims? Also, what about other ingredients in the supplement… is it safe to use?
Turmeric comes from the root of a plant that is often grown in India and parts of Asia. The root is ground into a powder that is used in food preparation mostly as a spice. It has also been used in eastern medicine for thousands of years.
Although adding turmeric into your diet can be a great idea, getting high enough doses to treat pain would require large amounts. Therefore the root has also been sold and studied as a dietary supplement.
Studies have shown that curcumin the active ingredient in turmeric is effective at treating numerous painful conditions. It does this through antiinflammatory and antioxidant effects.
The typical dose that helps relieve pain is around 500mg two to three times per day. It is recommended to not go above 2,000mg per day. Start with a lower dose and increase slowly to see how you tolerate it.
Quick Note On Dietary Supplements
It is important to remember that not all dietary supplements are the same. Look for one that carries the seal of USP (United States Pharmacopeia).
For Turmeric they recommend two products:
- Nature Made
Talk To Your Doctor Or Pharmacist
As with any supplement or OTC product you take it is important to discuss with your healthcare team. They need to know what you take in addition to any prescription medications you may be taking. There could be a chance for drug interactions.
In the case of turmeric at high doses it could act as a blood thinner. This may interact with other medications you take or be problematic if you have certain diseases.
You may also want to combine turmeric with other pain relievers if one doesn’t provide enough relief. This would also be a great topic of conversation with your healthcare team.
6. What Can I Take For Severe Pain?
In most cases severe pain will require a prescription medication. You may be able to take OTC medications or natural supplements with those medications. However you need to confirm that with your doctor.
Topical agents can also be a great way to target pain and be additive to stronger pain relievers.
Once you reach the point of severe pain you probably want to look into a comprehensive pain management plan. This plan would include not only drugs but lifestyle changes and coping mechanisms that can really help to alleviate the pain. In addition, this plan should try to solve the root cause of the pain in addition to just masking pain symptoms.
7. Key Points For OTC Pain Relievers
1. Don’t use NSAIDs for more than 10 days without talking to a doctor or pharmacist.
2. Look for signs of ulcers and stomach bleeding if you take NSAIDs often.
3. Think about acetaminophen if you have heart disease, high blood pressure, kidney disease or take blood thinning medication.
4. Many OTC medications contain acetaminophen. Don’t take more than the daily limit!
5. If you drink alcohol frequently then you may want to avoid acetaminophen.
6. Combining OTC pain relievers can be a great way to get pain under control.
7. Naproxen has a longer duration than Ibuprofen (12 hours vs 6-8 hours). Therefore, naproxen might be a better choice if you don’t want to remember to take the medication several times per day.
Click here to get Dr. Jason Reed’s exclusive list of medication questions you MUST ask your doctor, for FREE!
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Hewlings Susan J, et al. Curcumin: A review of its’ effect on human health. Foods. 2017:10:92-93.
Nissen, Steven E, et al. Cardiovascular safety of celecoxib, naproxen, or ibuprofen for arthritis. New England Journal of Medicine. 2016: 2519-2529.