NHOLUA The Dilemma of Drug Misuse-Abuse

Transcription

1 NHOLUA 2012 The Dilemma of Drug Misuse-Abuse November 13, 2012 Bruce W. Henricks, M.D. FACP Mutual of Omaha Quarry Oaks

2 Prevalence of Drug Abuse Introduction Drug abuse is often an occult problem in underwriting Recognition of cohorts where abuse is increasing What are they using? National Survey on Drug Use and Health (NSDUH) 2011 Statistics taken from over 67,500 survey participants annually Use of illicit Drugs 8.7% of the American population age 12 and older reported use of an illicit drug within the past month 22.5 million Americans Consistent with trends the last 5 years 2

3 Illicit Drug Use Types of Drugs used, by past Month Illicit Drug Users: 2011 National Survey, Analgesics Anxiolytics Sedative-Hypnotics 3

4 Illicit Drugs which predominate SAMHSA data

5 Case # 1 56 y/o F $500K, salary $35K Mortgage loan officer lbs PMH Wt down 14 lbs in the last year Multiple lumbar disc herniations and operative interventions,.otherwise unremarkable Healthcare maintenance timely and wnl Chronic lumbar pain Longstanding use of benzodiazepines and narcotic analgesics 5

6 Case #1 cont. Rxs Vicodin 1-2 q 4-6 hrs, averages 8-10/ day from pharm database Xanax.5 mg q 6-8 hrs PRN, though used daily Habits Labs Nontobacoo Enjoys 1-3 drinks / evening to help relax HDL 86, Chol 191, GGT 100, Alb. 3.7 ALT 31, AST 43 Questions at this point? Additional tests.that may allow an offer? Underwriting wanted a CDT, returned negative 6

7 Impact of the Baby Boomers The rate of lifetime illicit drug use is significantly higher among persons age years, the Baby Boomers 50% higher.than the mean for the general population Higher yet in those 55 years and older Prescription drug abuse from 1992 to 2009 increase 5x to 3.5% ~ 6% over age 50, used illicit drugs in the past year >1% abuse drugs and alcohol ~3% either dependent upon or abuse alcohol Rates higher for whites than other ethnic groups 7

8 Illicit drug use in Adults 50 to 59 8

9 Impact of the Boomers Baby Boomers (27.5% of the US population) Their higher prevalence of illicit drug use combined with their demographic impact supports The number of illicit drug users has, and will continue to increase Substance Abuse and Mental Health Services Administration.. (SAMHSA) data on addiction million over age 50 addicted to drugs Predicted to be 4.4 million by

10 Buyer Demographics Data from 2012 Median age of the adult US population 36.8 yrs Mutual of Omaha Average age at issue 47.5 yrs Impact of the Baby-Boomers (45-63 years old) Significant market influence on our industry Across all product lines 10

11 Past month illicit drug use by age 11

12 Impact of the Boomers 2007 DAWN data (Drug Awareness Warning Network) Decedents age years accounted for more than half of drug misuse deaths About 15,000 lives lost Actual figures likely higher due to under-reporting Large majority of drug-related deaths involve more than one substance > 60% of the time it s alcohol SAMHSA data Illicit drug use in those years Rose 243% from 2002 to

13 Case # 1 56 y/o F $500K, salary $35K Part-time loan officer lbs PMH Wt down 14 lbs in the last year Rxs Xanax, Vicodin (8/d) usage daily Uses alcohol daily somewhat to relax How much risk does she represent? 13

14 Case # 1 56 y/o F What rating covers her mortality risk? Standard or better Mild substandard (T3/C or less) Moderate substandard (T4/D to T6/F) High Substandard (T7/G or higher) Decline / Postpone 14

15 Case # 2 39M $1.5 million, salary $115K Sales Rep for Orthopedic prosthetics lbs Wife a pharmaceutical rep, no kids PMH Labs Nontobacco Lt inq. Hernia repair in 2009, otherwise benign TC 176, HDL 78, trigs 142, remainder of profile is WNL Urine. MJ 116 or THC (tetrahydrocannabinol) with application labs 15

16 Case # 2 cont. Drug and Alcohol Quest. Admits to occasional marijuana use; reportedly 2 weeks ago 1-3 drinks per day, admits to frequent entertainment of business clients What are the risks here? Additional tests? Can he be priced? What mortality is associated with marijuana? Medicinal marijuana The real dilemma created by state legalization of a schedule I drug Marinol by prescription a schedule III drug Anti-emetic in chemo, appetite assist in HIV 16

17 The most commonly used illicit drug Marijuana Estimated 17.5 million Americans are smokers of marijuana in the past month Each day, about 7000 try marijuana for the first time Rate of use increasing at about 7% per year About 2.7 million first-time initiates a year Common street names Pot, herb, grass, boom, weed, hash, ganja, blubbers, widow, dope Trademarked varieties Bubble gum, Northern Lights, Afghani #1, and Juicy Fruit 17

18 Marijuana Annual Numbers of New Users of Marijuana: National Survey, 18

19 Marijuana use by older Boomers 19

20 Marijuana Marijuana, cont. Accounts for over 75% of all current illicit drug use ~60% use marijuana exclusively About 5 million use it frequently Defined as at least 51 days per year Related mortality for frequent use is about 250% Data from the 1990 s 20

21 Case # 2 39M $1.5 million, salary $115K Sales Rep for Orthopedic prosthetics lbs Wife a pharmaceutical rep, no kids PMH Nontobacco Lt inq. Hernia repair in 2009, otherwise benign Labs TC 176, HDL 78, trigs 142, remainder of profile is WNL Urine. MJ 116 with insurance labs What rating is indicated? 21

22 Case # 2 39 y/o M What rating is appropriate for his risk? Standard or better Mild substandard (T3/C or less) Moderate substandard (T4/D to T6/F) High Substandard (T7/G or higher) Decline / Postpone 22

23 Case # 3 44 y/o F, divorced applying for $500,000 Ht 5 3, Wt 117 lbs (BMI 21) PMH Non-smoker Reported alcohol consumption: 3 drinks, 2-3x/wk with friends Negative w/u for atypical chest pain and insomnia MVR DUI in 12/08 with a BAC of.21 and successful completion of a state required alcohol awareness program Insurance labs: bili 0.7, AST 21, ALT 23, alb 4.4 Chol 180, HDL 86, trigs 73 23

24 Drinking and Driving: Patterns Drinking and driving has declined over the past 30 yrs The fatally injured driver: Is commonly white Doesn t wear a seatbelt, and has < a HS diploma Often the binge drinker Has a poor driving history 50% or more of the time 24

25 Assessing alcohol consumption Graduated-Frequency (GF) How often x number of drinks were consumed in a given period Correlates better with consumption Drinks/ day an unreliable assessment tool Allows for analysis of irregular and sporadic drinking patterns ( binge drinking ) Binge drinking in the US A binge = 5 or more drinks on one occasion in the past 30 days Highest in y/o s 25

26 Fatalities associated with BAC MR of 64 when BAC.10 or higher on a Friday or Saturday National Highway Traffic Safety Adm. (NHTSA) 26

27 Alcohol and Driving Driving Under the Influence of Alcohol in the Past Year by Age National Survey 2009, 27

28 Percentage Driving under the influence 28

29 Case # 3 44 y/o F What rating does she warrant? Standard or better Mild substandard (T3/C or less) Moderate substandard (T4/D to T6/F) High Substandard (T7/G or higher) Decline / Postpone 29

30 The Societal Impact of Alcohol NSDUH (National Survey on Drug Use and Health) Statistics Alcohol is used by > 50% of the population 1 in 8 adults have a drinking problem of misuse/abuse 22.6% participated in binge drinking 5 or more drinks on the same occasion at least once within the past 30 days 6.8% are heavy drinkers 5 or more drinks on the same occasion on at least 5 days in the past 30 Binge and heavy drinking highest in those aged % or more drive under the influence 30

31 Alcohol use by Age Current, Binge, and Heavy Alcohol Use by Age: National Survey 2010, 31

32 Features of Illicit Drug Abuse Occupational characteristics About 75% of drug users are employed Drug abuse is not exclusive to lower socioeconomic groups Characteristics Small businesses with 50 or less employees have the highest rates of use Commonly assume the majority will be young males with Less education and lower incomes 32

33 Illicit Drug Use Examples of occupational characteristics Jobs with disproportionately high rates of current illicit drug use Sales occupations Food preparation including Wait staff and bartenders Laborers, helpers, handlers Machine operators or inspectors Occupations are not the cause, But relate to demographic factors 33

34 Illicit Drug Abuse with Alcohol Incidence in certain occupations of illicit drug and heavy alcohol use by % Illicit Drugs Alcohol Professional specialty 5.1 / 4.4 Technical support 7.1 / 4.1 Executive and administrative 8.9 / 7.1 Machine operators & inspectors 8.9 / 9.0 Sales 9.1 / 4.1 Transportation & material moving 10.1 / 10.8 Construction 14.1 / 12.4 Food industry 18.7 /

35 Case # 4 50 y/o M applying for $2,500,000 Ht 5 11 Wt 186 lbs PMH: Meds: Klonopin.5mg at bedtime, Simvastatin 20mg/day MVR: clear Reported consumption: spirits or beer 1-3 drinks, 2-3x/wk No documented concerns in the APS Insurance labs: bili 0.65, AST 34, ALT 35, Chol 216, HDL 65, GGT 102, CDT (+) 35

36 Identifying the alcohol abuser Medical records Consumption often underestimated Labs Physicians may fail to ask about, record, or properly estimate true alcohol usage Commonly prudent to consider doubling what is recorded in the APS GGT Blood alcohol concentration (BAC) CDT 36

37 Current markers: CDT BAC CDT: most significant at younger ages BAC: elevated mortality ratios at all ages 37

38 Case #4 50 y/o M What rating is indicated? Standard or better Mild substandard (T3/C or less) Moderate substandard (T4/D to T6/F) High Substandard (T7/G or higher) Decline / Postpone 38

39 Case # 5 61 M for $ 3.5 million salary $425k CEO and majority owner of plastic fabrication plant Travels extensively for business and pleasure PMH L5-S1 microdiscectomy, Lt knee arthroscopy Rxs: baby ASA, folic acid, Vit D daily Chronic insomnia Tx Restoril, Klonopin Nontobacco Alcohol: 1-4 gl of wine/ day, occasional martini 39

40 Case # 5 cont. MVR, failure to yield, 15 mph over in 2010 Labs: AST 32, ALT 56, GGT 80 Chol 212, HDL 45, Trigs 174 Pharm database, confirms meds, plus Percocet Numerous prescribing physicians, from different states Risk assessment? What else can we learn? Value here of reflex testing., drug and alcohol questionnaire.is it worthwhile? 40

41 Illicit Drug Use in Boomers Past month illicit drug use among adults age National Survey, 41

42 Illicit Drug Use Demographics- New initiates New Initiates of Drug Use the last year: 2011 National Survey. 42

43 Types of Drugs Used Past month use of Selected Illicit Drugs in Persons aged 12 or older: National Survey, 43

44 Pain Reliever Misuse Annual Numbers of New Nonmedical Users of Pain Relievers National Survey, 44

45 Medication Misuse and Abuse Benzodiazepine misuse or abuse Valium, Xanax, Serax class of drugs Highest rates of abuse in those years Those years Showed an 80% increase from 1995 to 2002 Baby-Boomer effect Men are now just as likely as women to abuse psychotherapeutic medications 45

46 Sources for Prescription Misuse SAMHSA data from

47 Mortality considerations Known facts in drug-related deaths Twice as many men die, as women Males account for more than 70% of drug abuse-related deaths Impact of white Boomer men Overdose deaths account for more than 50% of drug abuse-related deaths Most accidental or unintentional > 70% of the time the second drug is alcohol 47

48 Prescription Drug Mortality Conclusions: Primary causes of death in patients on legal medications Accidents Due to acute intoxication Due to drug and alcohol interaction Suicides Use with malignancies for palliative care Terminal stages with analgesic use or dependence Increased mortality remained constant over time 48

49 Mortality Conclusions for Marijuana Recreational marijuana use NO excess mortality when variables below are factored out: Psychiatric illness IV drug abuse Prior police contact Rating STD to T4, for admitted users may be a consideration Dependent upon Company risk philosophy and tolerance S/t THC testing and drug questionnaire Mortality can approach T 8 on large populations of frequent users 49

50 Mortality Conclusions Prescriptions and non-medical abuse Legal drugs MR of 210% Chronic pain syndromes and analgesic use-abuse Legal drug and alcohol abuse MR of 340% Uncertainties of drug-alcohol interactions Significant negative impact on mortality when multiple drug(s) abused 50

51 US Recreational Drug Deaths 51

52 Tidbits to maybe, take home Don t underestimate the boomers Remember: Psychotherapeutic medications Impact of marijuana Interaction of alcohol Maintain a high index of suspicion 52

53 Questions?

54 References Substance Abuse and Mental Health Services Administration National Household Survey on Drug Abuse National Survey on Drug Use and Health National Institute on Drug Abuse The Drug Abuse Warning Network, The DAWN Report Bureau of Justice Statistics Cone EJ. Oxycodone involvement in drug abuse deaths. II. Evidence for toxic multiple drug-drug interactions. Journal of Analytical Toxicology. 2004;

55 References Bedell SE, Jabbour S. Discrepancies in the Use of Medications. Arch Internal Med. 2000; 160: Williams DS. Cocaine Revisited. Journal of Ins. Medicine. 2003; 35: Poser W. Mortality in patients with dependence on prescriptions drugs. Drug and Alcohol Dependence. 1992; 1: Andreasson S. Cannabis and mortality among young men: a longitudinal study of Swedish conscripts. Scand J Soc Med. 1990; 18: 9-15 Engstrom A, Adamsson C. Mortality in patients with substance abuse: a follow up in Stockholm County, Int. J Addiction. 1991; 1: Adamsson C. Has mortality in Drug Addicts Increased? Int J Epidemiology. 1997; 26:

56 References Gossop M, Stewart D. A prospective study of mortality among drug misusers during a year period after seeking treatment. Addiction. 2002; 97: Marzuk PM. Ambient Temperature and Mortality from Unintentional Cocaine Overdose. JAMA. 1996; 279: Lange RA. Cardiovascular Complications of Cocaine Use. NEJM. 2001; 345: Wood AJ. Drug Therapy, Androgens in Men- Uses and Abuses. NEJM. 1996; 334: Hyman SE. Drug Abuse and Addiction