Structural barriers in access to medical marijuana in the USA—a systematic review protocol

Medical marijuana use is predominant among white Americans, and less likely among Latino, Asian, and foreign-born individuals [8, 9]. There are few insights into why racial minorities in the USA have lower prevalence of medical marijuana use. Reinarman et al. [10] attribute the underrepresentation of Latinos’ use of medical marijuana to being a consequence of exclusionary immigration policies that hinder their participation in governmental programs [11, 10]. Due to the fear of immigration, certain ethnic minorities may not seek medical marijuana use despite their qualifying health conditions [10]. The association between race/ethnicity and levels of disposable income is cited as an underlying reason for why ethnic minorities in general might be less likely to use medical marijuana [12, 10]. Marijuana possession remains a federal crime, and ethnic minorities continue to be charged significantly more frequently than white males for marijuana-related offenses [13]. Therefore, the higher likelihood of ethnic minorities, such as Latinos and African Americans, being targeted by law enforcement or facing legal consequences for involvement with marijuana could also deter their use of medical marijuana [13].

Medical marijuana use is more common among individuals who are employed, have health insurance, and earn high incomes. For example, California residents earning over $60,000 are most likely to use medical marijuana [8]. Similarly, a major proportion (64.8%) of medical marijuana patients in medical marijuana assessment clinics across California reported being employed while almost three quarters (73.4%) of them had private health insurance [10].

Issuance of medical marijuana cards across states with MMLs usually has a financial cost. In certain cases, states may provide a cost subsidy for medical marijuana users who also qualify for federal assistance programs such as Medicaid or the Supplemental Nutrition Assistance Program (SNAP). In Arizona, for instance, the standard fee is $150.00 for both initial and renewal registrations for the state’s medical marijuana program; registrants must also have a valid referral from an authorized medical provider [14]. Neither the cost of receiving a medical provider referral nor the state registration fee is covered by health insurance. If the qualifying patient is currently participating in SNAP, they may register at a subsidized rate of $75.00 [14]. Thus, without sufficient disposable income, health insurance, or subsidies, individuals with qualifying medical conditions may be unable to participate in the medical marijuana program offered by their jurisdiction.

Stigma associated with possessing and using marijuana could further deter individuals from considering medical marijuana. For instance, the fear of labels such as “junkie” or “stoner” may dissuade patients with qualifying medical conditions from discussing medical marijuana use with their healthcare provider [15]. This fear could also prevent qualifying patients from visiting a licensed dispensary to purchase marijuana [15]. Statutes legalizing medical marijuana could reduce the stigma associated medical marijuana use due to the sheer increase in its availability (Pacula et al. [16]) and resulting social acceptability [5].

Another predictor of medical marijuana initiation and continuous use is physician attitudes. Under many state medical marijuana programs, a licensed physician must certify that a patient has a qualifying medical condition before that patient can access medical marijuana [3]. Depending on their source of information, physicians can be ambivalent about making these recommendations. In fact, many physicians cite the physical and mental health risks of medical marijuana as deterrents to recommending qualified patients [3].

Two further significant drawbacks to recommending medical marijuana are its classification as a “schedule I illegal drug” by the U.S. Drug Enforcement Administration and its unapproved status by the Federal Drug Administration [3]. The potential for physicians to resist recommending medical marijuana use is also identified in the literature. For example, 39% of specialists and 34% of primary care physicians in Delaware reported being “very unlikely” to authorize eligible patients for medical marijuana [17]. In addition, Satterlund et al. [15] found that patients do not initiate medical marijuana-related conversations with their primary care provider because of anticipated negative responses.

No previous systematic reviews have been conducted to assess the relative importance of the afore-discussed factors in influencing access to medical marijuana in the USA. Thus, the objective of this review is to summarize and critically appraise information regarding structural barriers to medical marijuana use in the USA (Arksey and O’Malley, [18]). The review will draw from the literature on the social determinants of health to identify established barriers of access to medication [7]. The structural barriers to access framework builds on the acknowledgment of structural violence as an impediment to health provisions [6]. Structural barriers in access to medical marijuana use in the USA have not been comprehensively analyzed, creating a gap in the literature. As medical marijuana programs proliferate across the USA, it is imperative to identify mechanisms driving the disparities to accessing this form of treatment. This review seeks to generate scientific evidence to fill the current gap in the literature, inform evidence-based policies and programs, and stimulate collective public health discourse on medical marijuana. Tackling structural barriers to medical marijuana access encourages equity across all adult patient population and aligns with the fundamental pursuit of public health research and practice.