Cannabis plantation for medicinal use
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Underwriting marijuana: A balanced approach is required

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    November 2023

    Marijuana use in the United States has exploded over the past decades, with legal sales of various products reaching an estimated $30 billion in 2022.1 To put it in perspective, this figure exceeds the total amount spent on chocolate and craft beer combined.2

    The CDC estimates there are more than 48 million users in this country, and according to the United Nations, marijuana (MJ) is the third most-used psychoactive substance in the world behind tobacco and alcohol.3 As such, it is prudent for underwriters of life, health, disability, and critical illness policies to understand the current research and underwrite accordingly, as our applicants and insureds are likely using these products in record numbers.

    map of legalization of marijuana in the US

    Underwriters and their medical directors are at a disadvantage, however, in determining the best approach to pricing excess morbidity and mortality. There are several factors at play, including: 

    1. The lack of good studies examining all-cause and cause-specific morbidity and mortality arising from the use of Cannabis sativa, along with its variants and subspecies, does not enable us to apply our general rules for underwriting and rating. These plants contain at least 500 different chemicals with THC, or delta-9 tetrahydrocannabinol, being the chemical of greatest concern. Any, or all of them, may predispose to excess mortality and/or morbidity—the absence of good studies precludes us from knowing with any degree of certainty the extent of this excess.4
    2. Various states of illegality, partial legality, and decriminalization of marijuana possession in some jurisdictions also inject a great deal of uncertainty into the equation of assessing excess morbidity and mortality. Marijuana is illegal at the federal level in the United States but is legal to varying degrees for medical and recreational use in several states. As long as it remains federally illegal, a black-market trade will continue in which MJ is sold at differing potencies and with the potential for the addition of various contaminants that impose a greater risk of bad outcomes. As an example, Abdallah, MD et al. reported a series of adolescents admitted to hospitals in Dallas, Texas, with e-cigarette or vaping associated lung injury, aka EVALI, in which the vast majority of the patients admitted to vaping THC that was later found to include vitamin E acetate. The vitamin E had been added to the THC oil to decrease the time it took for THC to enter the brain and exacerbate the “high.” This addition, however, resulted in severe lung injury that was likened to an “oil spill in the lungs.”5
    3. Marijuana has been challenging to study in the United States. The DEA currently includes MJ alongside heroin, LSD, methaqualone, and other similar drugs as a Schedule 1 drug with “no currently accepted medical use and a high potential for abuse.”6 This scheduling of MJ makes researching the drug and its effects on morbidity and mortality exceedingly difficult. Recently, this has been partially mitigated by the Medical Marijuana and Cannabidiol Research Expansion Act of 2022, which simultaneously rolls back restrictions on MJ research, speeds up the application process for interested scientists, and guarantees an adequate and uninterrupted supply of MJ for research purposes.7 An additional step to simplify the ability to study MJ has been recommended to the DEA by the Department of Health and Human Services, and this is to change the scheduling of MJ to Schedule 3, a class that includes “drugs with a moderate to low potential for physical and psychological dependence.”8

    Without studies to suggest how MJ use should be rated with respect to morbidity and mortality, it is necessary for us to understand the favorable and unfavorable associations of MJ and estimate the increased risk, if any, for this substance. I also find it helpful to consider what we know and don’t know when determining underwriting actions. 

    We know that MJ is not toxic with respect to mortality at any known dose, unlike many of the drugs we underwrite daily (e.g., opiates, benzodiazepines, antidepressants, etc.). We also know that MJ does seem to be helpful in certain medical conditions, especially chronic pain. Based on two papers published by Canadians in the Journal of Cannabis Research and the journal Cannabis and Cannabinoid Research by Bhaskar et al. and Bell et al., respectively, we begin to appreciate some consensus on the use of MJ for pain in a variety of conditions.9 The studies also recommended an approach to dosing both THC and CBD (cannabidiol).  

    While these “known” associations are favorable, there are also unfavorable associations between excess morbidity and mortality and MJ use. They include the following (noting that this list is not meant to be exhaustive):

    • Hjorthoj et al. recently published an article showing that cannabis use disorder (CUD) is associated with a significant increase in the risk for schizophrenia, a disease with significant excess morbidity and mortality. While the risk for developing schizophrenia was increased in both sexes at all ages, it was most pronounced in young men.10
    • The CDC estimates that CUD affects up to 30% of cannabis users.11 This disorder seems to favor heavy users at younger ages but can affect anyone who smokes their first joint or eats a THC-laced gummy. As with most drug use disorders, the symptoms include drug-seeking behavior, ongoing use despite problems in personal and professional relations, and withdrawal. Unlike withdrawal from many other drugs (e.g., alcohol, opiates, and benzodiazepines), withdrawal from THC is not directly life-threatening and has a shorter duration.
    • With respect to mortality, the National Academies of Sciences, Engineering, and Medicine, based on data gathered by the National Survey on Drug Use and Health in a report filed in 2017, showed a substantial association between MJ use and motor vehicle crashes, a moderate association with other accidents, and an increased incidence of suicidal ideation and attempt with completion in heavy users of THC. Concerning morbidity, this same group found associations with MJ use and chronic bronchitis, cognitive impairment in the domains of learning, memory, and attention in those who start using MJ at younger ages, worsening of anxiety and bipolar disorder, and limited evidence of MJ triggering myocardial infarction and ischemic stroke.12

    So, considering the favorable and unfavorable factors associated with MJ, as well as the knowns and unknowns, how does one underwrite individuals using this substance? In my opinion, it requires a balanced approach that proceeds as follows:

    • First, the data supports the fact that the most deleterious outcomes favor those using MJ at a younger age and those with either pre-existing psychiatric disease or those with signs and symptoms suggestive of significant but as yet undiagnosed psychiatric disorders. From the perspective of underwriting all insurance lines, this group is likely uninsurable.
    • We can add to that group those who exhibit any signs and/or symptoms of cannabis use disorder and those with a known history of substance abuse of other drugs (especially opiates and/or alcohol).
    • I believe both age and amount of use also impact the associated morbidity and mortality such that older people with less use are likely the better risks. Dare I point to Willie Nelson, a nonagenarian MJ user, to support this assumption?
    • Finally, in terms of pricing the excess risk, I recommend an approach that considers the overall health and well-being of the individual in question, the impact that MJ use may have on any underlying disease process(es), the age of the individual, and the amount and route of intake of THC and/or CBD before arriving at a course of action that should stand the test of time until we have better direct studies, which I hope will be forthcoming in the next few years.
    Contact the author
    John F. White III
    John F. White III, MD, MBA, DBIM, FLMI
    2nd VP Medical Director
    Medical Director, Munich RE US

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