Steve Urkel and caffeine is not a good combination

Caffeine as a gateway drug, part seven

If you’re new to Lessons on Drugs, welcome! This is part seven of the Caffeine as a gateway drug series where we explore how drugs work by examining the world’s drug of choice - coffee. In this post we’re looking at what happens when you take multiple drugs that have additive effects or work at cross-purposes to one another.

The challenge I’ve set myself is to try and explain how drugs work in enough detail to provide a proper explanation, without requiring people to have a heap of pre-existing knowledge of how the body works, ‘dumbing things down’ and being condescending. One of the things I’ve discovered along this journey is that it’s really bloody hard to do that, but I’m trying!

Here are all the links in order if you want to go back to check out any earlier posts before diving in to this one:

1. What coffee can teach you about how drugs work

2. How do you like your coffee - espresso or enema?

3. Do caffeine pills make you poop like coffee does?

4. Sesame Street pharmacology

5. When the smoke gets in your enzymes

6. The chemistry between us

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I was born in 1981, positioning me at the perfect maturity level to enjoy the low brow comedy of US sitcoms that were everywhere in the late 1980s. Full House, Saved by the Bell, The Fresh Prince of Bel Air…so many options, all of which included some sort of nerdy offsider.

(I acknowledge The Simpson’s also came out at this time with Millhouse who is possibly one of the best stereotyped TV nerds there is, but I can’t bring myself to refer to that show as ‘low brow’).

Each nerdy offsider had their trademark move, many of which I’d try to replicate which I’m sure was a complete delight for my family to endure. In my recollection of events, my Carlton dance was (and still is) pretty damn good, but I’m not so sure repetitively saying “Did I do that?” in a nasally high pitched voice would’ve been all that fun to be around.

“Did I do that?” was the catch phrase of TV’s biggest nerd, Steve Urkel, from Family Matters. Urkel was the annoying and intrusive neighbour to the Winslow family. He was a classical Revenge of the Nerds style nerd, complete with pocket protector, thick glasses, and allergies.

I haven’t been able to substantiate this, so it could be a false memory, but I think Urkel also used an asthma inhaler. I mean, what sort of stereotypical nerd portrayal would it be without an inhaler? So, for the sake of this story, let’s pretend he did. And let’s pretend that inhaler was salbutamol (or albuterol in the US) - the type of inhaler people commonly use to relieve their asthma symptoms.

Just to balance out the false idea that only nerds use inhalers, here’s Pedro Pascal to prove otherwise.

Back to Urkel and his imaginary inhaler.

As we talked about in part three of this series, drugs that are inhaled are typically used for their local effect on the airways. The desired local effect of the salbutamol (albuterol) is to relax the airways so breathing is easier.

Now, I’ve watched enough of these shows to know that the character with asthma is going to pull out their inhaler at every available opportunity. So I’m going to assume that Urkel is using a pretty high dose. As you’ll recall, higher doses increase the likelihood that some of the drug will be absorbed into the blood stream. And if a drug makes its way into to the general circulation, it’s going to give rise to some systemic side effects.

To understand what side effects we can expect, we’ve got to think about the drug’s mechanism of action, a concept which was introduced in our Sesame Street pharmacology crash course.

Salbutamol (albuterol) is a type of drug called a beta 2 agonist.

An agonist drug is one that mimics the role of a natural signalling pathway in the body. In this case, the drug mimics the action of hormones like adrenaline (epinephrine) and noradrenaline (norepinephrine) on type 2 beta adrenergic receptors. In technical language, we call these sympathomimetic effects, because they’re mimicking the actions of the body’s sympathetic nervous system - the fight, flight or freeze stuff.

The way these side effects can show up in your body is things like an increased heart rate and tremor. Because salbutamol (albuterol) crosses the blood brain barrier, central effects like headache, agitation and hyperactivity are also possible.

If you’re like me, and a bit of a delicate snowflake when it comes to these types of sympathomimetic effects, you might’ve had the unfortunate experience of experiencing these side effects yourself while sitting in the dentist chair shortly after receiving a local anaesthetic. There’s nothing like feeling anxious about having a dental procedure only to be given a drug that increases your heart rate, gives you the shakes, and makes you feel agitated. Fun stuff.

So if Urkel is like me, and gets the shakes when he uses his inhaler, its probably just one of those things he accepts as part of using his medicine. The trade off here is pretty obvious I think - experience some short term minor discomfort in order to keep breathing and stay alive.

Where things could get more interesting, and potentially more problematic, is if Urkel decided to use another substance that had a similar effect on his body. Like caffeine.

As we talked about in part four of this series, one of the main ways caffeine works is by blocking adenosine receptors. This shows up in your body as higher heart rate, tremors, and agitation, especially at higher doses.

So if Urkel was to get amped up on caffeine, not only would he be even more irritating due to his heightened alertness, but he’d probably also feel a bit rubbish. The salbutamol (albuterol) and the caffeine would both independently increase his heart rate, and contribute to tremor and agitation. This is an example of what we call an additive pharmacodynamic drug interaction.

As I was trawling the internet procrastinating trying to find confirmation that Urkel used an inhaler, I happened to stumble across an episode of Family Matters where this actually happened!

In the episode Life in the Fastlane, Urkel mistakes Laura’s diet pills for vitamins and takes them, getting even more out of control than normal. It results in him using a bunch of power tools in a very uncoordinated fashion, so who knows, maybe that’s the tremor and agitation due to a drug interaction at play.

I’m choosing to make the assumption that they’re caffeine diet pills and not amphetamines. Although, even if they were amphetamines, it would still be an example of an additive effect on alertness, heart rate and agitation.

(Side note - I’m not sure what was going on at this time in the world, but I feel like “diet pills are dangerous” was a recurring theme in the TV shows of my youth. It was definitely a story line in Saved by the Bell, and Beverly Hills 9021, which makes me think surely it must’ve featured in Degrassi somewhere along the line too. Between this and heroin chic fashion, how did any female possibly make it through their teenage years in 90s without some sort of diet and body image hang up?)

Sometimes, we use additive drug effects intentionally - like when two medicines that work in different ways are prescribed to reduce blood pressure, or to manage blood sugar levels in diabetes.

Other times though, these types of additive effects give rise to adverse effects. Because of this, it’s something you should watch out for if you’re taking multiple medicines, whether they’re prescribed, herbal or whatever. If you’re experiencing any niggling side effects, like stomach upsets, dry mouth, dizziness, something going on with how you pee, you’re feeling drowsy or fuzzy - anything like that that’s quietly bugging you, talk to your doctor or pharmacist about having a medicines review.

This Urkel story provides us with a half decent example of what an additive pharmacodynamic drug interaction could look like, but before I bring this post to a close, I should also mention the other type of pharmacodynamic drug interactions - opposing effects.

To illustrate this, let’s consider Urkel as a young man who was just trying to make his way in the world if it weren’t for his social challenges and people judging him so harshly all the time.

It doesn’t make it on the show (because I’m making it up) but part of Urkel’s back story is that he actually suffers from debilitating migraines. Has done ever since he hit puberty. So much so that he was prescribed a medicine called propranalol to try and prevent them.

Propranalol is a type of drug called a nonselective beta blocker.

Hang on a second Lauren, beta blocker? That sounds an awful lot like type 2 beta receptor agonist - are they related in some way?

Why yes, astute reader, they are.

While salbutamol (albuterol) acts as an agonist at type 2 beta adrenergic receptors, propranolol acts as a competitive antagonist. The propranolol drug molecule nestles itself into the receptor which blocks anything else from binding and triggering the cell’s intrinsic response. This includes stopping the salbutamol (albuterol) from binding and having its pharmacological effect. The two drugs are working at cross purposes. Urkel’s going to have to find a different way to prevent his migraines.

When it comes to prescription medicines, consideration of these types of drug interactions is something your doctor and pharmacist should have covered. However, they’re only able to work with the information they have access to. If you don’t tell them what you’re taking, chances are they don’t know.

These types of drug interactions don’t just occur between prescribed medicines - herbal products, supplements, over the counter medicines and illicit substances can also contribute. So, if you’re taking any medicines regularly, find a health professional you trust enough to be open and honest with so they can make sure your medication regimen is safe and effective for you. And to make it easier on yourself, keep an up to date list of all your medicines in your electronic medical record or the old fashioned way - a piece of paper still works just fine.

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Thanks so much for reading Lessons on Drugs! I hope you found it worth your time.

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Thanks again, and hope to see you back here next week for more. We’ve still got to cover how the drug gets out of the body…it might be time to talk about the pee pee.