Edition 2/2006
Underwriting Focus
Addiction
Addictive drugs are used widely in
many cultures in the world. The
point at which drug use can become an addiction and a threat to
health largely depends on the substance in question and the level of
consumption. Importantly, the legal
status of particular addictive drugs
has little or no bearing on the potential health risks.
Alcohol, tobacco and cannabis are
the most widely used psychoactive
substances. The reduction in age at
first use, the high risk of addiction
and the risk of serious organic dam-
Content
Addiction
Risk of Addictive Drugs
2
“Smoking is Bad for Your Health” 6
Diagnosis and Therapy for
Alcohol Dependency
7
Insurance Medicine Consideration
of Harmful Alcohol Use and
Alcohol Abuse
11
“Certified Medical Underwriting
Specialist (CII)” –
Graduation 2006
12
A Look Across the Fence:
Large Case Market in the UK
13
Seminar Dates
15
Imprint
16
A Berkshire Hathaway Company
age have made this an important
subject for underwriting.
This edition of Underwriting Focus
will consider several important
questions associated with addiction
including the factors that determine
the risk of addiction and the scale of
associated health risks. We will go
into detail about the risk for smokers
to suffer from atherosclerosis, carcinomas and respiratory diseases;
about opportunities concerning the
diagnosis and therapy of alcohol
dependency as well as point out the
perspective of insurance medicine.
Risk of Addictive Drugs
Prevalence
Dr. Raphael Gaßmann
Deputy Director at the
German Centre for Addiction Issues, Department of Policy Issues,
Hamm, Germany
A wide range of substances such as
cigarettes, alcohol, cannabis, heroin
and ecstasy are grouped together under the term “addictive drugs”. The
decisive factor is not the legal status
of the particular substance but the associated risk of addiction. As we will
see, the risk of developing a dependency, i.e. of no longer being able to
control consumption by the use of
free will, varies considerably when
viewed from different perspectives.
It should be emphasised from the
start that addictive drugs have been a
feature of human society across all
continents and throughout history,
mainly due to their “psychoactive” effects. These drugs can be considered
one of the basic constants of human
existence. However, there are great
differences in the reasons for and level
of usage. Drinking a glass of alcohol
or smoking a cigar a few times a year
can hardly be compared with the
daily consumption of several packets
of cigarettes or bottles of strong alcohol. We will therefore first discuss the
social status of consumption before
turning to the risks involved.
Consumption levels of the three
most widely used substances: alcohol, tobacco and cannabis are high
to extremely high in European
countries by comparison to other
countries. For alcohol e.g. Luxembourg, Hungary, Czech Republic,
Republic of Ireland, Germany and
Spain lead the list with an annual
consumption of more than 10 litres
of pure alcohol per capita, including
babies and the very aged (see
table 1).
Even among 15- to 16-year-old adolescents, the number who have not
drunk alcohol for at least one year,
in many countries is below 20 %, in
Austria, Czech Republic, Denmark,
Germany, Greece, Isle of Man,
Lithuania and United Kingdom even
below 10 % (Hibell et al., 2004). Almost 30 % of the 15-year-olds in Europe report regular drinking (The
European Health Report, 2005).
The World Health Organization
(WHO) estimates that almost one
billion men and 250 million women
in the world are daily smokers
(35 % of men and 22 % of women
in developed countries, and 50 % of
men and 9 % of women in developing countries), which represent approximately one-third of the global
population aged 15 and over
(WHO, Tobacco Control, 2004).
The average consumption is at 14
cigarettes per day and 80 % of adult
smokers started before the age of
18. Although over the past 25 years
the prevalence of smoking has
fallen in many European countries it
is still a major risk factor in health issues.
Cannabis is by far the illegal substance most commonly used. Recent population surveys indicate
that about 20 % of adults (aged 15
to 64 years) have tried the substance at least once. National figures vary widely, ranging from 2 to
31 %, with the lowest figures in
Malta, Bulgaria and Romania, and
the highest in Denmark (31 %),
Spain (29 %), France (26 %) and the
United Kingdom (30 %) (EMCDDA,
Annual Report, 2006). Cannabis use
is concentrated among young
adults, as other illegal drugs.
Among 15- to 24-year old Europeans, 9 to 45 % declared having
tried cannabis, with most countries
falling in the range from 20 to 35 %
(EMCDDA, Statistical Bulletin, 2005).
How many experimental users become dependent? (DSM IV)
35
31,9
30
23,1
25
20
16,7
15,4
15
9,1
10
5
0
Nicotine
Heroin
Cocaine
Alcohol
Figures in %
Figure 1: Experimental use and dependency (Source: IFT Munich, Germany)
2 Gen Re LifeHealth
Cannabis
Risk of addiction
World Alcohol Consumption
Litres of pure alcohol
Rank Country
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
Luxembourg
Hungary
Czech Republic
Republic of Ireland
Germany
Spain
United Kingdom
Portugal
Denmark
Austria
France
Cyprus
Switzerland
Belgium
Russia
Slovak Republic
Romania
Latvia
Netherlands
Finland
Greece
Australia
Canada
Italy
New Zealand
USA
Poland
Estonia
Japan
Argentina
Uruguay
Iceland
Chile
Bulgaria
Malta
Sweden
South Africa
Venezuela
Norway
Thailand
Brazil
China
Colombia
Taiwan
Mexico
Reliability 2000
**
*
*
**
***
*
***
*
**
**
**
***
***
***
*
**
**
*
***
***
*
*
***
***
**
**
**
**
**
*
*
**
*
*
*
*
**
*
**
*
*
*
*
*
*
12.5
10.9
11.0
10.7
10.5
9.8
8.4
10.8
9.5
9.2
10.5
7.4
9.2
8.5
8.6
8.9
7.4
7.7
8.2
7.1
8.0
7.4
6.5
7.7
6.8
6.8
6.7
5.6
6.5
6.4
6.0
4.7
5.3
6.3
5.2
4.9
4.8
5.0
5.0
4.4
4.2
3.9
4.1
3.0
3.2
2001
2002
2003
12.4
11.1
10.9
10.8
10.4
9.8
9.1
10.3
9.5
9.0
10.5
7.9
9.2
8.5
8.6
8.7
9.9
7.5
8.1
7.4
7.9
7.4
6.7
7.4
6.6
6.8
6.3
5.7
6.5
6.3
5.8
4.9
4.9
6.0
5.0
4.9
4.8
5.0
4.4
4.5
4.1
3.9
4.0
3.1
3.2
11.9
11.1
10.8
10.8
10.4
9.6
9.6
9.7
9.5
9.2
10.3
9.1
9.0
8.8
8.6
8.8
8.5
7.7
8.0
7.7
7.8
7.3
6.9
7.4
6.9
6.7
6.6
6.2
6.5
6.3
5.9
5.0
4.9
5.4
4.9
4.9
4.7
4.8
4.4
4.3
4.2
3.9
3.9
3.1
3.1
12.6
11.4
11.0
10.8
10.2
10.0
9.6
9.6
9.5
9.3
9.3
9.0
9.0
8.8
8.7
8.5
8.1
8.1
7.9
7.9
7.7
7.2
7.0
6.9
6.8
6.8
6.7
6.5
6.5
6.2
5.9
5.4
5.2
5.0
4.9
4,9
4.6
4.6
4.4
4.3
4.2
4.0
3.9
3.3
3.1
***= Very Reliable; **= Reliable; *= Less Reliable
Figures given in the table do not come from the same source. Differences can also be due
to variations in the definitions, the periods covered or the methods of calculation used.
Table 1: Total alcohol consumption by country 2000–2003, ranked in order of per capita consumption in 2003 (Source: World Advertising Research Center, World Drink Trends, 2005)
Just how high is the actual “risk of
addiction” associated with these
substances? How can we compare
them with each other? A good indicator is the relationship between
trying a substance and being considered dependent on it, by which
we mean an addiction based on internationally recognised diagnostic
criteria (DSM-IV or ICD-10). These
criteria paint a very differentiated
picture (figure 1):
Nicotine is at the top of the scale,
cannabis at the bottom. Two of the
main reasons for this appear to be
the time required for a drug to take
effect and the duration of the effect.
As a rule, the quicker a psychoactive
substance begins to take effect and
the shorter the duration of the effect, the greater the drug’s inherent
potential to trigger a desire for another dose.
Mortality risk
Each day, nearly 3400 people in Europe die from tobacco-related
causes. Assuming constant tobacco
use prevalence, WHO projects that
the annual number of deaths will
double in 20 years (WHO, Tobacco
Control, 2004).
Around 600 000 Europeans died of
alcohol-related causes in 2002, representing 6.3 % of all premature
deaths in the region that year. More
than 63 000 of those deaths were
young people aged 15–29 years.
The relative contribution to disability is even higher, with alcohol use
accounting for 10.8 % of the total
disease burden. This makes alcohol
the third leading risk factor for
death and disability in the Region.
Alcohol use increases the risk for
many chronic health consequences
(e.g. diseases) and acute consequences (e.g. traffic crashes).
Risk of criminality
Alcohol consumption also plays an
important role in serious crime. Indeed, the state of intoxication alUnderwriting Focus 2/2006 3
that shape the development and
degree of an addiction. Let us take
a closer look at these three factors.
60
50
40
30
The drug factor
20
10
0
Figures in %
Rape and sexual assault
Manslaughter
Resisting arrest
Robbery
Figure 2: Crimes committed under the influence of alcohol (Source: Egg, 2002)
most seems to regularly promote
the perpetration of certain crimes
(figure 2).
Psychoactive substances other than
alcohol are of no special relevance
in the commission of serious crimes
(not counting violations of drug
laws), a fact that highlights the especially destructive nature inherent
in the effects of heavy alcohol consumption.
The risk of dependence, the associated probability of illness or death,
of committing crimes and causing
accidents, all of these factors reflect
the probability of suffering measurable consequences of addictive
drug use. It is not difficult to imagine the severe social problems that
affect the victims’ personal and
work lives. The daily realities of dependence are violence, unemployment and impoverishment. A recent
study, for example, showed that
60 to 80 % of men who physically
abuse women do so under the influence of alcohol. The study further
concluded: “Children of treated and
untreated alcoholics represent a
high-risk group with respect to various behavioural problems and mental disorders” (Klein, 2003).
Risk factors
The question which factors increase
or reduce the risk of addiction remains unclear. The traditional
model identifies a triad consisting of
the individual, his environment and
the drug itself as the determinants
4 Gen Re LifeHealth
The different “addictive potential”
of various drugs was discussed
above (figure 1). In general, it is apparent that the risk of legal drug
use is often underestimated, while
that of illegal drug use is exaggerated. There is obviously no connection between the pharmacological
risk posed by a particular substance
and its legal status. This also holds
true in historical and international
comparisons and applies not least
to the question of prevalence: the
drugs used by the majority are no
less harmless than those used by a
minority.
The misconceptions that have
arisen in this regard can be best illustrated on the basis of the common gateway drug theory.
Cannabis was considered the perfect “gateway drug” for decades.
“It may be true that cannabis is not
dangerous in itself”, members of
young generations would be told,
mainly by members of older generations, “but it leads to the use of
harder drugs – and they are clearly
dangerous”. We now know conclusively that if a dangerous gateway
drug exists it is nicotine. The average age at entry for cigarettes is
around three years lower than that
for cannabis. Cannabis is almost always smoked (it is rarely drunk or
eaten) and around 95 % of regular
cannabis users are cigarette smokers. Since this became accepted as a
proven fact, the “gateway drug” argument has conspicuously fallen
out of usage.
The environment factor
The availability and consumption of
illegal drugs are greater in urban
settings than in rural ones, although
the difference is not as pronounced
as it was in the early 1990s – and
the gap continues to narrow. Alcohol-related problems among adolescents are much more prevalent in
agriculturally-oriented areas than in
major cities.
If we examine the environment factor on a small scale, we encounter
another popular misconception: it
has never been proven that participation in sports or membership of
sports clubs is linked to lower addictive drug use. On the contrary, a
recent European comparative study
found that, as expected, 14- to
16-year-olds consume alcohol relatively often and in large quantities
at clubs/discos – although that
venue ranked only second and, to
the surprise of many, was followed
by sports clubs.
The human factor
Boys and men are known to show a
greater propensity for errant behaviour than girls and women. This
tendency is also reflected in addictive
drug use. The most significant statistical differences continue to be gender-related: women account for
around two-thirds of prescribed
medication abuse cases. The situation is more than reversed with regard to the consumption of all illegal
substances, which tends to be a
male domain. Both sexes are roughly
equal when it comes to alcohol and
tobacco use. At some point, perhaps
in the 1970s, the consumption of
these substances among males must
have been so widespread that sociopsychological ostracism by women
became ineffectual. On the whole,
the use of addictive drugs declines
with age, which is mainly attributable, on the individual level, to a rising biologically related sensitivity to
psychoactive substances with age,
and, on the population level, to the
fact that long-term heavy drug users
generally die younger.
In addition, another misconception
relates to the “human factor”. In a
theological tradition, both addicted
and non-addicted drug users have a
weak character or dubious personality. Moral pressure on smokers and
campaigns directed at helping
young people to say ‘No’ to addictive drugs may support this. The attitude that only weak people use
addictive drugs persists despite the
primary reasons for individual drug
use being:
• the desire for relaxation and tranquillity
• the desire to be popular, cheerful
and interesting
• the desire to appear grown-up
and cool
• the attempt to increase performance by artificial means
• the need to cope with anxiety
and, finally
• the pleasure of intoxication
The view that these needs and desires are signs of a fundamental personal weakness are not credible. A
well-developed personality is of
more help when it comes to preventing consumption from turning
into a dependency or overcoming a
dependency (or integrating a dependency into the course of one’s
life with minimum negative effects).
However, whether a preference for
alcohol or cannabis over an evening
yoga course or an extreme sport
suffices to condemn a considerable
portion of the population is questionable.
Yet the question that should occasionally be explored is why the
actions of a growing number of
people are guided by the above motives to the extent that even different consumption patterns between
nations, regions, social levels and
genders are converging. This question can clearly only be answered
with the help of sociological tools.
Addictive drugs of the future
Although the consumption of psychoactive substances can be regarded as a basic constant of
human existence, as noted above,
there is a broad range of associated
risks for individual users and society
as a whole. The total scale of the
problem is apparently determined
by the social framework. This applies
in equal measure to prevention,
early intervention and treatment,
the possibilities of which are far from
being fully realised at present.
The goal is to prevent or delay the
onset of consumption, to promote
low-risk consumption and to reduce
the quantity – and thus the effects –
of consumption.
This challenge can only be met by
uniform, results-oriented and rational health policies relating to the
consumption of addictive drugs, regardless of whether they are legal
or illegal. The policies must be
based on knowledge rather than
doctrines. The approach should
centre on avoiding any manner of
encouragement or facilitation of addictive drug use. In concrete terms,
this means:
The basic principle of a health policy conceived along these lines is to
take all steps that have been proven
to reduce the spread of and harm
caused by addictive drugs and to
avoid doing anything that has been
proven to promote and stabilise
their use. The measures discussed
have been repeatedly and frequently evaluated internationally
with positive results. This concept
featuring a risk-minimisation approach that targets the health of
both individual users and the
population as a whole should be
systematically implemented. The
first important steps in this direction
have already been taken in many
countries.
• High prices for addictive drugs,
taxation programmes and elimination of the subsidisation of
wine and tobacco production
• Prohibition of all types of advertising for addictive drugs
• Prohibition of the sale of addictive drugs in vending machines,
at filling stations and “around the
clock”
• Ongoing mass media campaigns
for the prevention of addictive
drug use
• Widespread availability of fieldtested and target-group specific
early intervention and treatment
programmes partially financed by
alcohol and tobacco taxes
Underwriting Focus 2/2006 5
“Smoking is Bad for Your Health”
Elevated risk of atherosclerosis
Prof. Dr. med. Bernd
Krönig
Specialist in Internal
Medicine,
Trier, Germany
Smoking is the leading single cause of
death in Europe accounting for over a
million deaths each year. Prof. Krönig
provides an overview of the types of
organ damage to which smokers are
highly exposed.
Statistically, the health risk begins
with the consumption of 1–5 cigarettes per day and increases exponentially with the number of cigarettes smoked. For example, the relative risk of heart attack compared
with non-smokers (rated 1.0) grows
to 1.4 if 1–5 cigarettes are smoked
per day but soars to 9.2 if daily consumption exceeds 40 cigarettes
(INTERHEART). The risk of secondary atherosclerotic events and disorders such as stroke or peripheral
occlusive arterial disease increases at
approximately the same rate.
According to SCORE, the 10-year
risk of contracting a fatal cardiovascular disease doubles for a 55-yearold, normotensive male with normal total cholesterol levels from 2 %
for non-smokers to 4 % for smokers.
This is due to a smoking-induced
endothelial dysfunction that affects
rheological properties and, like high
blood pressure, can lead to atherothrombotic complications.
Carcinomas and respiratory
diseases
The large number of toxic substances in tobacco also make
smoking the primary risk factor for
malignant diseases. This applies
first of all to bronchial carcinomas
(10.8 times higher risk than non-
smokers), although cancer of the
larynx (5.4 times higher) and oesophagus (3.4 times higher) are attributable to smoking in over 90 %
of the cases. It is particularly tragic
that around 80 % of patients with
lung carcinomas are diagnosed too
late for (surgical) cure. Other forms
of cancer, such as cancer of the
stomach, pancreas, kidneys, bladder and cervix, are also more
prevalent among smokers.
Moreover, there is a high correlation between smoking and respiratory disease: the latest research suggests that up to 25 % of all smokers
will eventually suffer from COPD
(European Lung Foundation, 2006).
Hence, COPD has become the
fourth leading cause of death after
cardiovascular diseases and malignant tumours.
Risk reduction through smoking
cessation
The survival rate of a 35-year-old
smoker versus a non-smoker drops
from 91 to 81 % by age 60 and
plummets from 81 to 58 % by age
70. If, however, the subject manages to stop smoking, the risk of developing cardiovascular disease declines 2–4 years after withdrawal, although it takes 10–12 years to
achieve a significant reduction of
the malignant tumour risk. Compared to a permanent smoker, the
probability of contracting lung cancer at age 70, for example, falls
from around 10 to 4 % in the case
of a former smoker who gave up
the habit at age 50. We should not
neglect to mention that, with an
addiction potential of 30 %, nicotine poses the risk of long-term
drug use, especially among young
people.
All in all, smoking represents a huge
morbidity and mortality risk, which
can play an important role with
respect to both disability coverage
and risk stratification in life insurance.
6 Gen Re LifeHealth
Diagnosis and Therapy
for Alcohol Dependency
Epidemiology
Prof. Falk Kiefer
University of Heidelberg
Department of Addictive Behaviour and
Addiction Medicine
Central Institute of
Mental Health,
Mannheim, Germany
The per capita consumption of pure
alcohol in many European countries
is in excess of eight litres per year
[1] and is directly associated with alcohol-related secondary physical
disorders, alcohol abuse, alcohol
dependency and general mortality
[2; 3].
In Europe about 41 million adults are
estimated to abuse or be dependent
on alcohol, with the proportion of
men affected overwhelmingly higher
than that of women. Less than 10 %
of these people receive treatment.
This results in chronic illness and attendant social and economic consequences such as ill-health, early retirement and reduced life expectancy.
Data from the Epidemiologic Catchment Area (ECA) study indicate that
the lifetime prevalence of alcohol
abuse or dependence is 13.5 %.
Several million more people drink
too much and are at risk of alcohol
abuse (see text box for the definition of “harmful use” and “hazardous consumption”). However,
Professor Falk Kiefer provides an
overview of epidemiological data and
diagnostic methods. He also gives an
overview of the therapeutic measures
that can lead to abstinence rates of
60–70 % over the course of a year.
less than 10 % of those dependent
upon alcohol are undergoing therapeutic treatment for their addiction.
Thus, for example, 91 % of patients
in general hospitals with significant
alcohol problems are treated solely
for their somatic illnesses [4]; only
6 % of all those dependent upon alcohol attend clinics offering addiction therapy. It must be assumed
that in medical practices the percentage of patients with alcohol
problems is 17 % [5] and in general
hospitals as high as 20 % [6; 7].
Diagnosis
It is evident from the epidemiological figures and the inadequate pro-
Definition – Hazardous consumption, harmful use and alcohol
dependency
The World Health Organization (WHO)
assigns the responsibility for the diagnosis, treatment and some partial aspects of the prevention of “substanceinduced disorders” to the mental
health sector. In their current version
of the International Classification of
Diseases (ICD-10), the corresponding
diagnosis groups are precisely defined,
delimited and operationalised.
”Dependency“ is deemed to exist
where at least three of the total of six
criteria were demonstrable during the
course of a year:
• a strong desire or sense of compulsion to take alcohol
• difficulties in controlling alcohol-taking behaviour in terms of its onset,
termination or levels of use
• a physiological withdrawal state
when alcohol use has ceased or
been reduced
• evidence of tolerance, such that increased doses of alcohol are required in order to achieve effects
originally produced by lower doses
• progressive neglect of alternative
pleasures or interests because of alcohol use
• persisting with alcohol use despite
clear evidence of overtly harmful
consequences
“Harmful use” should be distinguished from alcohol dependency.
This used to be termed “abuse” and
defines a consumption pattern which
results in physical or mental health disorders directly attributable to alcohol
consumption but without fulfilling the
dependency criteria.
“Hazardous consumption” derives
from the average daily volume or actual consumption. The WHO cites a
daily alcohol consumption of 20 g
(0.2 l of wine or 0.4 l of beer) for
women and 40 g (0.4 l of wine or 0.8 l
of beer) for men as the threshold
value, stating that if this value is exceeded within an inter-individually
varied period of time it results in incidences of health damage. Many experts consider this threshold value to
be excessively high.
Underwriting Focus 2/2006 7
vision of addiction specific medical
care that a great deal of emphasis
must be given to early detection of
alcohol related problems. In practice, clinical signs are initially followed up with screening the alcohol-related laboratory parameters
such as gamma glutamyltransferase
(gamma GT), the transaminases
(ALAT, ASAT), the mean volume
(MCV) and the carbohydrate-deficient transferrine (CDT). However,
for the identification of more hazardous consumption and even dependency, laboratory values alone
furnish inadequate information and
suspicions must be clarified in a
direct interview with the patient.
However, these indirect methods
entail the risk of wishing to find the
patient guilty on “circumstantial
evidence”, thus triggering defensive
and denial strategies.
For the attending physician, deranged laboratory values are the signal to complete the diagnosis. For
simple and standardised application
e.g. the Alcohol Use Disorder Identification Test (Audit, Audit-G-M) [8]
has stood the test of time. Whereas
the full version of the more sensitive
AUDIT appears too time-consuming
in the primarily medical field,
AUDIT-C [9] can be recommended
for day-to-day practical application
(see text box below).
Given a positive screening using this
instrument the dependency symptoms cited in the text box should
be clarified in interviews.
• Feedback – apprising the patient
of the personal risk of drinking
Therapy
• Advice – issuing clear advice and
goals
Fundamentals and motivation treatment
The therapeutic recommendations
in the case of harmful alcohol use
and dependency are predicated
upon the degree of seriousness of
the disorder and the most pressing
therapeutic objectives. Although
treatment resulting in “lifelong abstinence” constitutes the ideal, it
may not be achievable and can
even demotivate the patient. In
such cases, periods of abstinence interrupted by relapses constitute a
major therapeutic success when
compared to untreated “chronicprogressive” development.
The primary treatment objective is
that the motivation to become abstinent should supplant the motivation to drink. Motivation promotion
and stabilisation is a task, not a precondition, of therapy. The following
factors have proved helpful with regard to motivation generation and
consolidation (“FRAMES” according
to Bien [10]):
AUDIT-C – Screening Test for Alcohol Problems
How often do you drink alcohol?
Never
Once a month or less
Two to four times a month
Two to three times a week
Four times a week or more
❏
❏
❏
❏
❏
0
1
2
3
4
When you drink alcohol how many
glasses do you normally drink in a
day?
(one glass of alcohol corresponds to 0.33l of
beer, 0.25l of wine/sparkling wine, 0.02l of
spirits)
One to two glasses per day
Three to four glasses per day
Five to six glasses per day
Seven to nine glasses per day
Ten or more glasses per day
8 Gen Re LifeHealth
❏
❏
❏
❏
❏
0
1
2
3
4
How often do you drink six or more
glasses of alcohol when an occasion
arises (e.g. during dinner or at a
party)?
(one glass of alcohol corresponds to 0.33l of
beer, 0.25l of wine/sparkling wine, 0.02l of
spirits)
Never
Less than once a month
Every month
Every week
Once a day or almost every day
❏
❏
❏
❏
❏
0
1
2
3
4
Given an overall points total of four
and above in the case of men and
three and above in that of women the
test is positive in the sense of an enhanced risk for alcohol-related disorders (hazardous, harmful or dependent alcohol consumption) and thus indicates the necessity for further action.
• Responsibility – emphasising personal responsibility for change
• Menu of behaviour change – indicating behavioural alternatives
• Empathy – applying a non-confrontational method of conducting interviews
• Self-efficacy – reinforcing the
self-efficacy of the patient
The main feature of a motivational
interview method is to avoid forcing
dependent patients onto the defensive by confrontational means. Instead, open questions devoid of implied assessment, encouragement
to perform self-assessment with reflected listening and positive feedback, will motivate them to recognise the problem and demonstrate
a willingness to change. Additional
key features of a motivational interview method are an empathetic approach, the development of faith in
self efficacy and the agreement of
jointly set treatment goals.
The effectiveness and the
favourable cost-benefit ratio of
short-term intervention within the
framework of primary medical care
can be confirmed [11]. Measures
initiated by general practitioners,
such as providing information, enlightenment and advice, lasting a
maximum of thirty minutes encourage up to 50 % of patients to reduce their alcohol consumption
[12]. The effects of a short term intervention are demonstrable up to
48 months following the initiation
of such measures.
Withdrawal treatment
(“detoxification”)
Once alcohol dependency has
been diagnosed and the patient is
prepared to abstain from alcohol
the first stage of the therapy involves alcohol withdrawal treatment.
Withdrawal treatment can be administered on an outpatient basis if
no indications of impending withdrawal complications remain.
Complications can be expected
where there is a history of severe
withdrawal symptoms, delirium,
multiple drug abuse, psychiatric or
somatic co-morbidity (particularly
cardiovascular), social instability
and drinkers of more than 150 g/d
per day. In the simplest case withdrawal is effected by means of a
medically accompanied reduction
in the volume of alcohol which is
imbibed. Pharmacological treatment is necessary in the case of
approximately one third of patients.
In this case, combination therapy
involving tiapride and carbamazepine, by means of which the
vegetative withdrawal symptoms
can be easily controlled and the relapse prophylaxis simultaneously
maintained, has proved its worth.
Patients are seen every day on an
outpatient basis, with detoxification
being concluded in the majority of
cases after five days.
If inpatient treatment is necessary
to achieve withdrawal, this should
be delivered in the addiction department of a psychiatric clinic. In
addition to differentiated diagnosis
and treatment of the withdrawal
symptoms, therapeutic measures
boosting motivation to achieve abstinence and behaviour or lifestyle
change can be initiated here [13].
Without motivational support
purely physical withdrawal results in
high relapse rates or unfinished
treatment. However, at this point
the prerequisites for developing and
stabilising behavioural changes are
good. Associated therapy with
drugs such as Chlormethiazole or
Diazepam has proved successful although both are unsuitable for outpatient treatment due to their addictive potential and side effects
that can endanger the patient.
Rehabilitation (relapse prophylaxis)
For a long time, inpatient withdrawal treatment (“long-term therapy”) was the key factor in the rehabilitation of alcohol dependent
patients. Over the course of the last
few years, treatment has increasingly included elements of behavioural therapy. These encompass
analysing relapse situations, roleplay relating to relapse prophylaxis,
social competence training and alcohol exposure training. In particular, this treatment endeavours to activate personal resources, especially
coping skills. Behavioural patterns
and habits which underpin addiction are analysed from the standpoint of their conditioning factors
and changed by means of alternative forms of behaviour. Social integration and personality development are therapeutic goals which
are fostered by means of the inclusion of relatives and increased
contact with people or addiction
problems, or through vocational
rehabilitation.
An evaluation of the therapy reveals
abstinence rates of 46 % after four
[14] and 40 % after ten years [15].
However, there are indications to
the effect that comparable results
can also be achieved for some patients with less time and effort [16;
17]. Nevertheless, overall, it is undisputed that inpatient long-term therapy will also be necessary in the future for a number of people with severe alcohol problems, especially
given the fact that a correlation
probably exists between therapy duration and success [18]. According
to a multi-centric German study
conducted at 21 inpatient treatment
clinics involving 1410 patients, after
eighteen months 53 % and after
four years 46 % of the alcohol dependent patients were abstinent
throughout the entire follow up period [19]; a further 8.5 % and 3 %
had improved after eighteen
months and four years respectively.
Other studies also achieve the same
abstinence rates. In the case of patients repeating withdrawal treatment there was still an abstinence
rate of 39 % (after eighteen months).
Outpatient withdrawal treatment is
usually administered by psychosocial advisory agencies (addiction
advisory agencies) or established
psychiatrists and psychotherapists
with appropriate addiction treatment experience. Indication criteria
for an outpatient treatment can be
the following:
a) a level of social integration
which, existing problems
notwithstanding, is still good
(family, employment)
b) the ability to embark upon and
maintain an abstinent phase
upon the commencement of
withdrawal treatment
Given a therapy frequency of onetwo hours a week, a treatment duration of approximately one year
can be expected. Treatment can be
administered in the form of group
therapy or individual courses of
treatment.
For the purpose of outpatient care,
the possibility of administering a
Underwriting Focus 2/2006 9
pharmacological relapse prophylaxis (“anti-craving treatment”) has
existed for some years. The effectiveness of the glutamate modulator
Acamprosate, which was introduced in Germany in 1996, in the
relapse prophylactic treatment of alcohol dependency has been examined in seventeen placebo controlled studies over the course of
the last few years; the meta analyses
of clinical study data result in a percentage of constant abstinence after six months of 36.1 % when undergoing Acamprosate treatment
compared with 23.4 % under
placebo conditions and an effective
strength of 0.26 [20; 21]. The percentage of patients needing treatment for relapse avoidance purposes (numbers needed to treat,
[NNT]) is 7.5 % [21].
The drug treatment should be complemented by attendance of selfhelp groups (e.g. Alcoholics Anonymous) and, ideally, also by courses
of addiction specific outpatient
therapy such as those on offer from,
for example, addiction advisory
agencies.
Summary and Future Perspectives
In order to improve the range of
courses of treatment available to
people with alcohol problems, more
systematic diagnoses and primary
interventions are needed. The majority of those dependent upon
alcohol do not access addiction
therapy due to shame, insecurity
and apathy which contributes to the
repression of their alcohol problem.
Given problematic consumption not
involving dependency symptoms,
minimal medical intervention using
motivational interviewing techniques is frequently effective and results in a reduction in the volume of
alcohol consumed. If dependency
continues and a course of addiction
therapy is initiated, decoupling substance intake from substance effect
is a necessary treatment objective.
Relapses are an expression of the seriousness of the illness. The therapy
should be designed along polypragmatic lines and all symptomatic
measures contributing towards the
10 Gen Re LifeHealth
establishment and maintenance of
abstinence (inpatient and outpatient
courses of therapy, addiction severity reduction drugs, self-help groups
psycho-social measures) should be
encompassed. The central effective
factor, which results in long-term
withdrawal, follows on a secondary
basis through experience of and
competence in mastering addictive
situations on an abstinent basis; in
other words, by decoupling addiction associated stimuli and substance intake.
11 Küfner H. Ergebnisse von Kurzinterventionen und Kurztherapien bei Alkoholismus – ein Überblick. Suchtmedizin 2000; 2: 181–192.
12 Moyer A, Finney JW, Swearingen CE,
Vergun P. Brief interventions for alcohol problems: a meta-analytic review
of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction 2002;
97(3): 279–292.
13 Miller W R, Rollnick S. Motivierende
Gesprächsführung. Ein Konzept zur
Beratung von Menschen mit Suchtproblemen. Freiburg: Lambertus 1999.
14 Küfner H, Feuerlein W. Inpatient
treatment for alcoholism, a multi-centre evaluation study. Berlin: Springer
1989.
Literature:
1
World Advertising Research Center,
World Drink Trends, 2005.
2
Edwards G, Anderson P, Babor T F et
al. (eds.). In: Alcohol policy and the
public good. New York: Oxford University Press 1994.
3
Her M, Rehm J. Alcohol and all-cause
mortality in Europe 1982–1990: a
pooled cross section time-series analysis. Addiction 1998; 93: 1335–1340.
4
John U, Hapke U, Rumpf H J, Hill A,
Dilling H. Prävalenz und Sekundärprävention von Alkoholmissbrauch und
-abhängigkeit in der medizinischen Versorgung. Baden-Baden: Nomos 1996.
5
Hill A, Rumpf H J, Hapke U, Driessen
M and John U. Prevalence of alcohol
dependence and abuse in general
practice. Alcohol Clin Exp Res 1998;
22: 935-940.
6
John U, Rumpf H J, Hapke U. Estimating prevalence of alcohol abuse in one
general hospital. Alcohol and Alcoholism 1999; 34: 786-794.
7
Volz M, Rist F, Alm B. Screening auf
Alkoholprobleme in einer chirurgischen
Abteilung mit Hilfe des Kurzfragebogens LAST. Sucht 1998; 44: 310–321.
8
Babor T F, de la Fuente J R, Saunders
J, Grant M. The Alcohol Use Disorders
Identification Test: Guidelines for use
in primary health care. Geneva: World
Health Organization 1992.
9
Bush K, Kivlahan D R, McDonell M
B, Fihn S D, Bradley K A. The AUDIT
alcohol consumption questions (AUDIT-C): An effective brief screening
test for problem drinking. Arch Int
Med 1998; 158: 1789–1795.
10 Bien Th, Miller W R, Tonigarn J S.
Brief interventions for alcohol problems: a review. Addiction 1993; 88:
315–36.
15 Mann K, Czisch P, Mundle G. Psychotherapie der Alkoholabhängigkeit.
In: Soyka M, Möller H-J, eds.: Alkoholismus als psychische Störung. Heidelberg, Springer 1997: 119-135.
16 Mann K, Batra A. Die gemeindenahe
Versorgung von Alkoholabhängigen.
Psychiatrische Praxis 1993; 20: 102-105.
17 Mann K, Ackermann K, Günthner A,
Jung M, Morlock P, Mundle G.
Langzeitverlauf und Rückfallprophylaxe bei alkoholabhängigen Frauen
und Männern – Abschlussbericht
BMBP-Projekt. Tübingen 1996.
18 Sonntag D, Künzel J. Hat die Therapiedauer bei alkohol- und drogenabhängigen Patienten einen positiven
Einfluss auf den Therapieerfolg, Sucht
2000; 46, Sonderheft 2: 92–176.
19 Küfner H, Feuerlein W, Huber M. Die
stationäre Behandlung von Alkoholabhängigen: Ergebnisse der 4-Jahres
Katamnesen, mögliche Konsequenzen
für Indikationsstellung und Behandlung.
Suchtgefahren 1988; 34: 157–271.
20 Mann K, Lehert P, Morgan M Y. The
efficacy of acamprosate in maintaining
abstinence in alcohol-dependent individuals: results of a meta-analysis. Alcohol Clin Exp Res 2004; 28: 51–63.
21 Berglund M. A better widget? Three
lessons for improving addiction treatment from a meta-analytical study. Addiction 2005; 100(6): 742–50.
Insurance Medicine Consideration of
Harmful Alcohol Use and Alcohol Abuse
Marlis OstermannMyrau
Chief Medical Advisor,
Gen Re LifeHealth
[email protected]
Alcohol is the most widespread addictive substance used in Europe. Dependency and harmful use occur in all
age groups from the age of approximately fifteen upwards. Ready made
alcoholic drinks or “alco pops” with
their sweet and pleasant taste are
specifically aimed at adolescent
drinkers. The average alcohol content
of these drinks is 5–6 volume %. In
the critical development phases of
adolescents this can be particularly
harmful. In a period during which
young people are maturing (up until
approximately the age of seventeen)
curiosity, impulsiveness and dependency are present in the minds in equal
measure.
However, alcohol is also a luxury good
and, as such, modern life is no longer
conceivable without it. It is frequently
the case that this border between
abuse and indulgence is blurred. This
makes it difficult for all underwriters
to make an assessment which is in
line with the actual risk.
Indicators of alcohol-toxic
damage
that of women (Federal Bureau of
Statistics, causes of death statistics).
Laboratory
• suspicious: typical laboratory mosaic: MCV+, yGT/PT+, uric acid+,
triglyceride+
• chronic liver damage: additionally, alkaline phosphatase+,
bilirubin(+)
• cirrhosis of the liver: additionally,
Quick/INR-, cholinesterase-
In addition to acute intoxication,
withdrawal delirium and the results
of accidents, the causes of death
particularly encompass internal
clinical pictures.
Case history in connection with the
pathological laboratory (see above)
• gastro-intestinal complaints, e.g.
gastro-oesophageal reflux, Mallory-Weiss syndrome, diarrhoea,
irritable colon syndrome
• disordered actions of the heart,
absolute arrhythmia, holiday
heart syndrome
• steatosis hepatica (sonographically evidenced)
• pancreatitis
• epilepsy
• exhaustion syndrome(s)
• increased perspiration
• anxiety and excitation
• depression
In 1997, in Germany for example
the average age at alcohol-induced
death was 56.3 years: 55.9 years in
the case of men and 57.4 years in
The most important life-threatening
illnesses for life insurance are as follows:
1) steatosis hepatica, chronic alcohol-induced hepatitis, cirrhosis
of the liver
2) acute pancreatitis, recurrent
acute pancreatitis, chronic pancreatitis
3) intestinal cancer
4) cancer of the mouth, throat cancer, laryngeal cancer and oesophageal cancer
5) alcoholic cardiomyopathy
In addition, incidences of secondary
neurological and mental alcohol related damage are of relevance to
disability products since they almost
invariably trigger a claim. These encompass:
• epileptic fits
• polyneuropathy of the legs
• alcohol-toxic cerebro-atrophy
(both the cerebellum and the
cerebrum may be affected by the
However, due to the incidences of
multi-form damage resulting from
chronic alcohol abuse, diagnosing
hazardous and harmful use of alcohol and alcohol dependency is extremely important.
Underwriting Focus 2/2006 11
symptoms of gait disturbance,
speech disorder, tremor due to
cerebellar damage and impairment of the cognitive faculties
due to cerebral damage)
• alcoholic psychoses – character
changes (a psychotic delusion of
jealousy is frequently described.
A character change is the most
severe consequence of alcohol
abuse since it impacts all interpersonal and social relations and
involves interactions)
Insurance medical risk
Generally speaking, incidences of alcohol-related damage develop
slowly and progressively over a long
period of time. An individual can
live in society for many years without any health problems or complaints and without visiting a doctor. However, given the enormous
prevalence of alcohol abuse this
means that some of the at-risk persons have already been in our port-
folio for many years and are accounted for in the basic premiums.
For life insurers it is important to be
aware of incidences of advanced
health damage. In disability business we must be on our guard if
and when high liver function values
are found; psycho-physical clinical
pictures in consequence of excessive alcohol consumption almost invariably result in occupational disability.
“Certified Medical Underwriting Specialist (CII)”
– Graduation 2006
From 10 to 14 June 2006 underwriters from primary insurers all
over Europe attended Module 4 of
the Gen Re Medical Underwriting
Programme in Cologne organised
by the Gen Re Business School. Participants who successfully complete
all requirements of the course programme acquire the qualification
“CUS – Certified Medical Underwriting Specialist (CII)”. The programme has been accredited by the
Chartered Insurance Institute CII
under its Continuous Professional
Development Accreditation Programme.
The international medical underwriting seminar as a comprehensive
and practice orientated concept
was launched in 1997 and trains
enrolees as professional underwriters in a four modular programme.
The course includes life, critical illness and disability underwriting and
covers medical and non-medical
underwriting topics.
12 Gen Re LifeHealth
Participants Module 4, June 2006, Certified Medical Underwriting
Specialist
A Look Across the Fence:
Large Case Market in the UK
Lynn Baillie, Senior Underwriter at
Gen Re UK, talks to Steven Simkin,
Chartered Insurer, employed in an underwriting development role at Standard Life. With 10 years underwriting
experience which also included
claims, Steven Simkin spent several
years within a dedicated team dealing
with large case underwriting and still
remains involved in the large case
market primarily through auditing
and business development opportunities.
Lynn Baillie
Senior Underwriter
Gen Re UK, London
In the UK what is the large case
market?
The large case market refers to life
and disability risks of a high sum assured. Companies have different
perceptions of what constitutes a
“high sum assured” but common
levels are over € 700 000 (life cover)
and over € 500 000 (Critical Illness
Cover/TPD). The large case market
is made up of large personal risks
and large business related risks.
Specific training is usually required
to ensure underwriters understand
the role of financial underwriting
and are equipped to underwrite financial evidence. In addition, the
background to some large cases can
be very complicated and whilst
training cannot always compensate
for experience, an awareness and
understanding of common situations is essential.
What is the role of a large case
underwriter in this market?
What challenges do underwriters
face when assessing large risks?
The role of the large case underwriter varies. He needs to
Underwriters face many challenges
when assessing large risks and these
challenges manifest in several ways:
• understand the needs of the customer and identify those propositions which are realistic, sensible
and likely to go and stay “onrisk”
• ensure the client/adviser understands why financial underwriting
is necessary
Steven Simkin,
Underwriting Development Consultant,
Standard Life, Scotland
Is specific training required?
• ensure expectations are set with
the client and adviser
• consult and work with the reassurer (if necessary)
• financially and medically underwrite the application – ensuring
all necessary evidence requests
are made at an early stage (if possible)
• work in partnership with the adviser and sales force to ensure all
relevant evidence is obtained in a
timely manner
• obtaining the relevant underwriting information, particularly of a
financial nature
• obtaining underwriting information within appropriate time
frames
• dealing with advisers and clients
who may have little experience of
the large case market and how
this works
• trying to establish whether the
sum assured is appropriate to the
circumstances under consideration
• working in partnership and negotiating with the adviser, the client
and the reassurers to ensure a
successful underwriting outcome
• build relations with the adviser
and, where appropriate, provide
guidance as to how future applications could be successfully submitted
Underwriting Focus 2/2006 13
In the UK there are only a few
insurers who cater specifically for
large risks, why is this?
• access to the necessary underwriting information – particularly
relating to the financial aspects
The large case market can be complicated and the range of services
required (spanning underwriting,
administration, legal, technical etc)
is considerable. The costs associated
in supplying these services by experienced professionals will be significant – particularly when you also
consider the cost of underwriting
evidence and the lapse and NPW
rates experienced with protection
business. Insurers must therefore
have serious intentions about writing business in the large case market and consider the market to be
profitable before deciding if they
can justify putting in place the necessary infrastructure.
• a sensible sum assured which can
be reasonably justified from the
information provided
Is a dedicated experience team
essential?
A dedicated team ensures a concentration of expertise and experience.
In addition, case ownership not
only aids efficient underwriting but,
importantly, helps build relations
with advisers which can foster repeat business introductions. A dedicated team and case ownership
provides that crucial point of contact which ensures any obstacles are
overcome with the minimum fuss.
What are the key recipes to a successful large case proposition?
Key recipes to a successful large
case proposition are:
• a well completed application
form, financial questionnaire and
summary of case background (if
appropriate)
• an open and effective dialogue
between the underwriter, the
adviser and reassurer
14 Gen Re LifeHealth
• a clear protection need/shortfall
• a dedicated underwriting team
with case ownership
• an efficient Medical Service to
arrange the necessary requirements
How does the role of a reassurer
fit into the proposition?
The reassurer adds value through
the provision of guidance and support for complex risks and in formal
ways such as training courses. In addition, the reassurer enables the direct office to write large risks above
normal retention limits by sharing
the risks with the direct office (via
the provision of capacity) and also
provides a path to the retrocession
market.
Do you foresee a future for large
cases especially given merging
companies and reduction in retrocession capacity?
There already exists a real and sustainable demand for protection in
the large case market. For example,
IHT liability will continue to drive
applicants to ensure protection
needs are appropriately insured and
this demand is likely to increase as
property prices rise. Insurers and reassurers will continue to provide
services and offer capacity to enable
these risks to be written in the future. Changes within the reassurance market may mean the quantity and quality (in terms of sums
assured) may not be written in the
future but for as long as the demand exists then the supply will
too.
What drives a successful portfolio;
price or service?
Price will always be an important issue but, in the large case market,
service is a key differentiator and a
world class service proposition will
make for a successful portfolio. Of
course, service doesn’t simply refer
to the underwriting aspect but also
the arrangement of medical requirements, technical and legal support, efficient administration and
supporting literature – the whole
package is important. Customer
feedback confirms the relevant importance of service versus price.
Is the relationship with the sales
force important?
The underwriter can only write the
business if the enquiry or proposal
comes our way. Therefore, a strong
relationship between the adviser
and our sales force will help send
the business to the underwriter
who, in turn, then has the opportunity to sufficiently impress the adviser to send more business our
way. The sales force can also support the underwriter by ironing out
any local difficulties or issues that
may occur.
Do you have special arrangements for medical evidence?
We use a Medical Service who efficiently arrange and co-ordinate all
the relevant requirements (with the
obvious exception of the GPR) at a
“one-stop” appointment.
Crucially, direct contact to the Medical Service is available to the adviser which ensures they remain
fully informed as the case proceeds.
Seminar Dates 2007
Gen Re Medical Underwriting Programme
Course 2006/2007
Module 3: 8 to 12 January 2007
Module 4: 11 to 15 June 2007
Course 2007/2008
Module 1: 22 to 27 April 2007
Module 2: 10 to 14 September 2007
Please register for Module 1 of the Gen Re Medical Underwriting Programme
2007/2008 by 30 March 2007. For registration forms and further details please
contact Markus Burbach (+49 221 9738 796, [email protected]).
ICLAM 2007
From May 6 – 9 2007 the 22nd International Congress of Insurance
Medicine ICLAM will be held in Berlin, Germany. Underwriting and
claims specialists, medical doctors as well as actuaries are invited to take
part in the lectures and workshops.
Detailed information on the scientific and social programme, accommodation and fees is available on the website www.iclam2007.de.
Underwriting Focus 2/2006 15
Impressum RPaktuell 2/2001
Kölnische Rückversicherungs-Gesellschaft AG
Theodor-Heuss-Ring 11
50668 Cologne, Germany
PO Box 10 22 44
50462 Cologne, Germany
Phone +49 221 9738-0
Fax
+49 221 9738-494
www.genre.com
© Kölnische Rückversicherungs-Gesellschaft AG
2006
Underwriting Focus is a publication of the
Gen Re Business School.
Edited by
Production
Dr Marianne Kutzner (Managing Editor),
Anke Siebers, Klaus-R. Pannenberg
Phone +49 221 9738-678
Fax
+49 221 9738-824
www.genre.com/business-school
Druckhaus Locher GmbH, Cologne
The published articles are copyrighted. Those which are written by specified authors do not necessarily constitute the opinion of the publisher or the
editorial staff.
All the information which is contained here has been very carefully researched and compiled to the best of our knowledge. Nevertheless, no responsibility is accepted for accuracy, completeness or up-to-dateness. In particular, this information does not constitute legal advice and cannot serve as a
substitute for such advice.