5.1 Cannabis, Hallucinogens, Dissociatives, Inhalants, and Nicotine

Why remaining Domain I.D classes still count

The IC&RC Alcohol and Drug Counselor (ADC) Examination weights Domain I: Scientific Principles of Substance Use and Co-Occurring Disorders at 25% of scored content. Task I.D in the ADC Candidate Guide (effective November 2022; PDF posted July 2025 at https://internationalcredentialing.org/wp-content/uploads/2025/07/ADC-Candidate-Guide-2022.pdf, checked 2026-09-20) requires candidates to differentiate among common substances of abuse and their characteristics. Alcohol, benzodiazepines and other sedative-hypnotics, stimulants, and opioids have their own Domain I sections. This section covers the remaining classes that still generate exam items and weekly caseloads: cannabis, classic hallucinogens, dissociatives, inhalants, and nicotine. This section is independent ADC study material by OpenExamPrep. OpenExamPrep does not claim IC&RC approval, partnership, or exact equivalence with IC&RC courseware. Official items, scoring, and candidate rules remain IC&RC and member-board products.

You will not be scored on writing a natural-products dissertation. You will be scored on whether delta-9-tetrahydrocannabinol (THC) is the intoxicating cannabinoid, why cannabinoid hyperemesis syndrome (CHS) is not treated by giving more cannabis, why phencyclidine (PCP) looks like a medical emergency rather than a quiet LSD trip, why an inhalant collapse can be sudden sniffing death even on an early episode, and how nicotine replacement therapy (NRT) differs from varenicline.

At Riverside Counseling Collective, counselor Priya Nair meets Jordan Hale, age 24. Jordan dabs high-potency cannabis several times a day, vapes nicotine almost continuously, uses nitrous oxide canisters on weekends, and last month smoked a joint a friend later said may have been laced with PCP. Jordan arrived after three emergency visits for cyclic vomiting that briefly settled in scalding showers. Priya's Domain I job is to sort those drugs by receptor story, expected signs, and dangerous myths before any later screening tool is opened.

Cannabis: THC, CBD, potency, and CHS

Cannabis products deliver a mix of cannabinoids. THC is the primary psychoactive constituent. It is a partial agonist at cannabinoid type 1 (CB1) receptors in brain and gut. Cannabidiol (CBD) is not intoxicating at ordinary retail doses; it has low CB1 agonist activity and must not be taught as the source of the high. Clients confuse CBD oils, delta-8 products, and high-THC concentrates. Edibles delay onset (often 30–90 minutes, peaking around 2–4 hours), so people redose and then become far more intoxicated than they intended. Smoked or vaped THC rises in minutes and typically peaks within about half an hour.

DSM-5-TR cannabis intoxication is recent use plus a clinically significant behavioral or psychological change and two or more of conjunctival injection, increased appetite, dry mouth, and tachycardia within about two hours. Anxiety, perceptual distortion, and panic can appear, especially in naive users or after high-THC concentrates. Synthetic cannabinoids sold as K2 or Spice bind CB1 more unpredictably and can produce agitation, seizures, and medical instability beyond typical plant cannabis.

Cannabis withdrawal (taught with other withdrawal syndromes as a non-seizure picture) is irritability, anxiety, insomnia, strange dreams, restlessness, and decreased appetite after stopping heavy daily use. That gut story is the opposite of CHS.

Cannabinoid hyperemesis syndrome — also called cannabis hyperemesis — is recurrent nausea, vomiting, and cramping abdominal pain in people with frequent, long-term cannabis use, including synthetics. Three phases are described: a prodromal phase of morning nausea and fear of vomiting; a hyperemesis phase of intense cyclic vomiting; and a recovery phase after abstinence. Many clients take compulsive hot showers or baths during attacks. Hot-water bathing is strongly associated and useful in history-taking, but it is not unique to CHS (cyclic vomiting syndrome can look similar) and is not a required Rome IV criterion. Standard antiemetics often fail. Some emergency departments use topical capsaicin cream on the abdomen as a temporizing measure. The 2024 American Gastroenterological Association clinical practice update treats sustained cannabis cessation as the intervention that reliably stops the cycle. Using more cannabis because it helps nausea is a high-yield exam trap. Jordan's showers and ongoing dabs are CHS clues, not proof that withdrawal has started.

Hallucinogens: LSD, psilocybin, and MDMA

Classic serotonergic hallucinogens such as lysergic acid diethylamide (LSD) and psilocybin act primarily as 5-HT2A agonists. Pupils dilate. Perception, time, and meaning shift. Synesthesia can occur. Vital-sign changes are usually moderate compared with stimulants. Death from a pure LSD overdose is rare; trauma, panic, and dangerous behavior are the practical risks. Counselors watch for hallucinogen persisting perception disorder (HPPD) (ongoing visual disturbances after the drug has cleared) and for a rare persistent psychosis in vulnerable people.

3,4-methylenedioxymethamphetamine (MDMA) (ecstasy, molly) is often grouped with hallucinogen-related teaching even though its street identity is an empathogen. It releases serotonin, with dopamine and norepinephrine contributions. Bruxism, thirst, hyperthermia, and hyponatremia from overwatering plus an antidiuretic-hormone-like effect are the medical cluster. Combining MDMA with monoamine oxidase inhibitors (MAOIs) — and to a lesser extent some other serotonergic drugs — raises serotonin syndrome risk. After a weekend run, a midweek crash with low mood is common and should not be automatically labeled independent major depression on day two.

Dissociatives: PCP and ketamine

PCP and ketamine are N-methyl-D-aspartate (NMDA) receptor antagonists. They disconnect perception from ordinary sensory input. PCP intoxication can look like a medical emergency: nystagmus (including vertical or rotary), muscle rigidity, blank stare, analgesia, hypertension, hyperthermia, and unpredictable agitation. Superhuman strength is mostly analgesia plus adrenergic drive, not a comic-book power, but staff still need a calm, low-stimulation approach and medical backup. Ketamine is shorter-acting and used in anesthesia and some depression protocols; nonmedical use can produce a profound dissociative K-hole. Chronic heavy ketamine is associated with ulcerative cystitis and urinary frequency — a medical complication counselors should not dismiss as anxiety.

Do not treat PCP as just another LSD. The toxidrome, violence risk, and medical workup differ. Jordan's possible laced-joint episode belongs in the dissociative column if nystagmus, rigidity, or blank-stare analgesia showed up, not in the 5-HT2A column by default.

Inhalants: hypoxia and sudden sniffing death

Inhalants include volatile solvents (glue, paint thinner, gasoline, toluene), aerosols, gases (butane, propane, nitrous oxide), and nitrites (poppers). They are cheap, rapid, and over-represented in adolescents. Intoxication is brief euphoria, dizziness, slurred speech, and ataxia, then a crash. Hypoxia is inherent: the user is displacing oxygen, depressing ventilation, or both.

Sudden sniffing death is an abrupt fatal cardiac arrhythmia. Halogenated hydrocarbons and fuels can sensitize the myocardium to catecholamines. A startle, a chase, or a surge of epinephrine then triggers ventricular fibrillation. It can occur on a first or early episode, not only after years of white-matter injury. Chronic use adds leukoencephalopathy, hearing loss, peripheral neuropathy, bone-marrow suppression, and renal tubular acidosis (especially toluene). Heavy nitrous oxide use inactivates vitamin B12 and can produce spinal-cord neuropathy. Jordan's weekend nitrous is not harmless whipped-cream culture; it is an inhalant with a neuropathy and hypoxia story.

Naloxone does not reverse inhalants. Rescue is airway, oxygen, and emergency medical services. Later counseling that it was only air freshener is not a safety plan.

Nicotine, NRT, and varenicline

Nicotine is a nicotinic acetylcholine receptor agonist that also drives mesolimbic dopamine. Cigarettes, smokeless tobacco, and e-cigarettes all deliver nicotine; combustion products add cancer and chronic obstructive pulmonary disease (COPD) risk. Population harm from tobacco dwarfs most other drug classes counselors see, which is why nicotine belongs in remaining I.D teaching even when a program still treats cigarettes as a break-area afterthought.

NRT supplies nicotine without smoke. Patches are long-acting basal replacement. Gum, lozenges, inhalers, and nasal spray are faster, used for breakthrough craving. Combining a patch with a short-acting form often works better than one product alone. Teach correct gum technique (park-and-chew) so clients do not underdose and then call NRT useless.

Varenicline is a partial agonist at α4β2 nicotinic receptors: it reduces withdrawal by providing partial stimulation and blocks nicotine from cigarettes from producing a full reward. Typical counseling timeline is start about one week before the quit date and continue about 12 weeks, following the prescriber. The U.S. Food and Drug Administration (FDA) removed the neuropsychiatric boxed warning in December 2016 after the EAGLES trial showed serious psychiatric event rates were lower than post-marketing fears had suggested, including in people with stable psychiatric illness. Mood should still be monitored because quitting itself can unmask irritability and depression. Brand Chantix left the U.S. market after a 2021 nitrosamine recall; generic varenicline is the current product. Bupropion sustained-release is another FDA-approved cessation medicine. ADC counselors generally do not prescribe; they screen tobacco use, educate, and coordinate with a prescriber. That is Domain I knowledge in service of later referral tasks.

Exam traps

• CBD is not the intoxicating CB1 agonist; THC is.
• CHS happens during ongoing heavy use; cannabis withdrawal cuts appetite. More cannabis is not the treatment for CHS.
• PCP is an NMDA dissociative, not a 5-HT2A classic hallucinogen.
• Sudden sniffing death is arrhythmia, not a naloxone event, and not reserved for chronic users.
• Varenicline is a partial agonist, not naloxone-for-cigarettes, and the boxed warning has been gone since 2016.