Download Marijuana use: implications for life insurance Marianne E Cumming

Marijuana use: implications for life insurance
Marianne E Cumming MD
Swiss Re Claims L&H - 2015: First Quarter Issue
Marijuana use: implications for life insurance
Did you know that cannabis is the most abused substance
worldwide? Find out more about cannabis use and the
implications for life and health insurance in this fascinating article
by Dr. Marianne Cumming, MSc, MD, Medical Manager for
Swiss Re's Life & Health Products Division.
Introduction
Globally, cannabis is the most widely used substance of abuse with estimates of
between 119 million and 224 million users worldwide. The most recent United
Nations World Drug Report indicates cannabis use is highest in North America, Europe
and Australia and New Zealand (1). According to the National Survey on Drug Use and
Health (United States), non-medical marijuana accounts for more than 80% of all
"illicit" drug use in the US with almost 8% of the US population reporting current
marijuana use (2). Until recently, marijuana could be easily categorized along with
other illicit, also termed illegal, drugs. This distinction between illicit (illegal) compared
with licit (legal) drugs easily separated these categories of drugs. Recently, however,
the general trends towards decriminalization and the further step of legalization of
marijuana use in some jurisdictions mean the lines are blurred. Legalized medical
marijuana brings its own challenges with much debate about indications, dosages and
current practice. With wider availability and misconceptions about safety, marijuana
use appears to be increasing, particularly at younger ages. Potent plants, lack of
standard formulations, and limited long term carefully designed studies contribute to
the unknown risks associated with marijuana use. These have important implications
for life and health insurance.
Marijuana: the product
Marijuana, the dried leaves and flowering tops from the hemp plant, Cannabis sativa,
is the most common form of cannabis used in North America. Cannabis resin, the
pressed secretions of the plant known as hashish, may be more common in Europe.
Cannabis oil, a product of distillation, is another product from the hemp plant.
Cannabis contains more than 400 active chemicals, including more than 60 unique
cannabinoids, which warrant further characterization.
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Marijuana use: implications for life insurance
Marianne E Cumming MD
The major psychoactive ingredient, delta-9-tetrahyrdocannabinol (THC) is the active
ingredient that determines the potency of marijuana.
Another active ingredient, cannabidiol (CBD), is thought to offset some of THC's
negative effects, but it is sometimes bred out to increase the psychoactive THC
potency.
Inhaled marijuana smoke produces rapid excitatory, psychoactive effects which peak
at 15 to 30 minutes and last up to 4 hours. An estimated 2 to 3 mg of inhaled THC
may produce psychoactive effects. Non-medical (recreational) use commonly involves
smoking of the dried plant. THC content in the dried plant has increased compared to
40 years ago and may range from 1 to 20%. One joint of dried marijuana may contain
25-150 mg of THC. THC may also be extracted to create a highly concentrated (6099%) product to be ingested by smoking or vaporization.
Marijuana ingested mixed with food products has a delayed onset of psychoactive
effects ranging from 30 minutes to 3 hours which may last up to 12 hours. An
estimated 5 to 20 mg of ingested THC may produce psychoactive effects. THC content
in food products varies widely, but a single marijuana cookie may contain up to 100
mg (3).
Interestingly, marijuana for medical use has not been regulated in the same manner as
other medications derived from natural sources. In the US, marijuana is classified by
the Drug Enforcement Agency (DEA) Controlled Substances Act as a Schedule 1 drug
which means it is not recognized as having any current acceptable medical use and it
is consider high potential for abuse. Legalized medical marijuana at the state level
predates provisions for standard medical formulations.
The most common form of medical marijuana in the USA is dried plant products
without standard THC potency and some users grow their own supply. In Canada,
dried plant is also available for medical use, through a Health Canada supplier or with
a personal production license. Synthetic THC formulations, indicated for
chemotherapy-induced emesis and HIV or cancer-related anorexia, are available in
both US and Canada. An herbal cannabis extract in the form of an oral spray is
approved for neuropathic and cancer pain in Canada and is an investigational drug in
the US.
Marijuana: medical use
At the time of writing, medical marijuana programs are in place in 23 US states and
Washington DC. An additional 11 states have limited access laws, and legislative
activity around marijuana continues. Medical marijuana is available all across Canada.
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Marijuana use: implications for life insurance
Marianne E Cumming MD
In general, the intent of legalization for medical use is to provide compassionate
treatment for individuals suffering from debilitating medical conditions. Although
marijuana has reportedly been used for medical purposes for over 100 years, it has
not yet been extensively studied as a therapeutic agent.
The expanding lists of indications for medical marijuana are not yet supported by long
term efficacy or safety studies. Indications may include malignant and non-malignant
pain conditions, chemotherapy-induced nausea, cachexia and weight loss related to
cancer or HIV disease, muscle spasticity, multiple sclerosis, Parkinson’s disease,
spinal cord injuries, seizure disorders, glaucoma and other less common conditions.
Treatment guidelines, optimal dosages and formulations of medical marijuana are not
well delineated.
Limited studies have identified medical marijuana users as a potentially higher risk
group. Medical marijuana use is more common in young males with chronic pain.
Chronic pain medical marijuana users are more likely to have moderate-to-severe
widespread pain, more likely to be tobacco users and more likely to have problems
with alcohol and other substance (cocaine) abuse. (4,5).
Marijuana: medical risks
Marijuana's behavioral effects may include euphoria, relaxation, altered time
perception, impaired concentration, memory and learning, as well as possible panic or
paranoid reactions. Physiologic effects may include increased heart rate, respiratory
rate and diastolic blood pressure, dry mouth and throat, and increased appetite.
Colorado's legal non-medical retail sale, purchase and possession provisions, which
were implemented in 2014, have led to expected medical consequences including
increased health care utilization, emergency room visits, and exacerbation of
psychiatric conditions. Unexpected consequences include an increase in marijuanarelated burns, and unintentional ingestion of edible products, particularly in children,
leading to hospital and intensive-care unit admissions (6).
Marijuana dependence is reported in about 10% of users. Studies of adverse effects of
marijuana are limited by sample size and selection, study duration, and confounding
factors. Systematic reviews of available studies report a probable association between
marijuana smoking and chronic bronchitis, and a possible association with respiratory
(lung, head and neck) and bladder cancers. Marijuana use is associated with mental
disorders, most consistently with psychosis, particularly with young age (<18 years) of
initiation or with longer duration of use.
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Marijuana use: implications for life insurance
Marianne E Cumming MD
Associations with depression, suicide, other substance abuse, impaired educational
attainment and cognitive impairment have been reported. Individuals with mental
disorders are more likely to be cannabis users, accounting for 72% of cannabis users
and 82% of those with Cannabis use disorders. Marijuana has also been associated
with increased risk of infections, ischemic stroke and other vascular events (7-16).
While marijuana's morbidity risk is recognized, mortality risk is less clear. Toxicity and
lethal dose data related to marijuana are limited but it is believed to have a high safety
margin with case reports primarily of coma, particularly children, after oral ingestion.
However, marijuana is associated with other substance misuse and has been
associated with increased mortality in substance users in treatment. While deaths
from cannabis overdose alone are unlikely, it is more often found with other drugs in
fatal overdose drug deaths and is also associated with cardiovascular deaths and
accidental death risk (motor vehicle crashes, intentional injuries) (17).
Marijuana: detection and impairment
Marijuana THC metabolites may be detected in saliva, blood, and urine with urine as
the preferred sample because of higher concentration and longer detection times. A
positive urine THC indicates marijuana use in the recent past but this depends on the
specific pattern of use. With chronic use, it is difficult to determine whether a positive
test indicates current use or is a result of residual drug being excreted over time. A
positive result may indicate acute marijuana use within 1 to 3 days or chronic use for
3 or more weeks.
Marijuana is second to alcohol as the most common non-medical drug associated with
impaired driving. Marijuana metabolite levels indicate presence of the drug but do not
necessarily correlate with behavior impairment. In contrast to alcohol which has well
delineated predictable levels and limits, there is no widely accepted limit for
impairment with other drugs including marijuana. State laws for impaired driving with
drugs include “per se” laws that indicate it is illegal to operate motor vehicle with any
detectable blood level of prohibited drug and/or its metabolites and other state laws
which define “drugged driving” as driving when a drug “renders the driver incapable of
driving safely” or “causes the driver to be impaired”. Since retail availability of
marijuana in Colorado, an increase in marijuana positive fatal crashes has been
reported (18) and cannabis has been associated with a 4-fold increased risk of traffic
collisions (19).
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Marijuana use: implications for life insurance
Marianne E Cumming MD
Marijuana: Implications for insurance
Marijuana is already the most common non-medical ("recreational") drug worldwide.
Global cannabis cultivation is widespread while limited legal access and provisions for
medical use are recognized in several countries. Trends towards public acceptance,
decriminalization, medical use and perceptions of safety all will likely contribute to
further increased prevalence of use, particularly at younger ages. Public interest and
legislative activities are likely to continue.
Prevalence of marijuana use in insurance applicants and policy holders is presently not
well delineated. Only a minority of insurance companies routinely test for marijuana
metabolites during the application process. Preliminary insurance applicant data
suggests an estimated prevalence of urine THC in the 3-4% range or likely half
compared to the general population. Positive urine THC is more common in applicants
who are also positive for tobacco metabolites (urine cotinine) compared with cotinine
negative applicants.
Underwriting risk assessment may be enhanced by the addition or expansion of urine
drug screening for marijuana and possibly other substances. At time of underwriting,
careful consideration of admitted or detected marijuana use is warranted. An
underwriting focus on details of marijuana use, quantity, frequency and method of
ingestion, use of alcohol or other drugs including prescription drugs with abuse
potential, identification of associated psychiatric and medical conditions, social and
occupational factors and level of functioning will be beneficial for accurate risk
classification.
Research studies to determine optimal use of cannabis products for medical
impairments have been limited, given marijuana's federal status as a Schedule 1 drug
with no recognized legitimate medical use. Presently, medical marijuana may be used
in place of established and effective treatments for a variety of medical conditions.
Renewed scientific interest will hopefully lead to further studies to better define
medical uses, dosages, delivery systems and the safety profile of medical marijuana
products. Studies will also hopefully lead to better understanding of the medical and
societal risks associated with cannabis products.
Limited data suggests that, in isolation, marijuana itself has a high median lethal dose
and a relatively favorable safety profile. However, other studies have demonstrated an
association of marijuana with excess death risk, including traffic fatalities, most often
through association with the frequently co-existing mental disorders or other
substance abuse.
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Marijuana use: implications for life insurance
Marianne E Cumming MD
Through these associations, marijuana use may contribute to increased accidental
death risk particularly at younger ages. The impact is potentially significant given low
expected death rates.
In general, cannabis psychoactive potency, defined by THC content, has increased
over recent years. Blood levels of marijuana metabolites do not necessarily correlate
with impairment. Research to further define impairment in relation to drug levels is
ongoing. Current state impaired driving laws rely on subjective criteria to determine
impairment status, which are open to interpretation.
Legal provisions, public acceptance and potentially expanded drug testing may lead to
changes in patterns of applicant disclosure of marijuana use. With medical use, it may
be challenging during claims assessment to correlate THC levels with prescription
instructions given the lack of standardized formulations or dosages and limitations of
drug level analysis. Policy language, which may use the terms "legal" and "illegal" to
differentiate drugs according to categories of risk, warrants further review. With
legalization of marijuana, the lines are blurred and these distinctions may no longer
apply.
Marijuana use is an important consideration for life insurance companies. Current
evidence related to the possible benefits and risks associated with marijuana is limited
but ongoing studies should contribute to further understanding of risks relevant for life
insurance companies.
References
1 UNODC, World Drug Report 2012 (United Nations publication, Sales No.
E.12.XI.1).Drug Report 2012
2 Substance Abuse and Mental Health Services Administration, Results from the 2013
National Survey on Drug Use and Health: Summary of National Findings, NSDUH
Series H-48, HHS Publication No. (SMA)
14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration,
2014.National Survey on Drug Use and Health 2013
3 Sharma P, Murthy P, Srinivas Bharath MM. Chemistry, Metabolism, and Toxicology of
Cannabis: Clinical Implications. Iranian J Psychiatry 7:4, Fall 2012
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Marijuana use: implications for life insurance
Marianne E Cumming MD
4 Aggarwal SK, Pangarkar S, Carter GT, Tribuzio B,Miedema M, Kennedy DJ. Medical
marijuana for failed back surgical syndrome: a viable option for pain control or an
uncontrolled narcotic? PM R. 2014;6(4):363-372.
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Marijuana use: implications for life insurance
Marianne E Cumming MD
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