But like all swiftly embraced changes in public health, there can be unintended consequences of legalizing cannabis for medical uses. My colleagues and I are seeing this one: the rise of a new health care disparity, because it is harder for poor people to access medical cannabis than it is for wealthier people.
Since 1996, I have worked as a primary care physician in the Bronx, N.Y., home to several of the county’s poorest congressional districts. Two years ago, we started a medical cannabis practice in one of our busiest primary care practices to better serve people with chronic pain — one of the qualifying conditions in New York state for the use of medical cannabis. Each year, our practice sees thousands of patients with chronic pain stemming from conditions such as degenerative joint disease, inflammatory arthritis, HIV, sickle cell anemia, fibromyalgia, and neuropathy.
Medical cannabis is a good option for them. In fact, data from the first two years of New York state’s Medical Marijuana Program show that more than 70% of registered patients seek medical cannabis to treat chronic or severe pain, often in an effort to avoid prescription opioid medications.
In addition to certifying patients for medical cannabis, I educate them on the potential harms of cannabis and on how to obtain legal, highly regulated, non-smokable medical cannabis from legal dispensaries. I always recommend that patients purchase particular tinctures or oils based on the relative quantities of the two common compounds in medical cannabis: cannabidiol (CBD) and tetrahydrocannabinol (THC).
Unfortunately, most patients do not follow through on my recommendation.
Of nearly 500 chronic pain patients certified to use medical cannabis in our practice to date, fewer than half reported purchasing it at a licensed dispensary — largely because they cannot afford it. Because the federal Drug Enforcement Administration still classifies medical cannabis as a Schedule I substance, insurance doesn’t cover it. For the same reason, it can’t be bought using a credit card. For my patients, monthly cash-only payments run from $200 to $300. While this is manageable for some people, the majority of my patients find this to be a very heavy burden.
On top of the high cost of medical cannabis, it is available only at licensed cannabis dispensaries. These are few and far between. My patients usually need to take a multi-leg bus, train, and subway ride, or a costly car service. While the distance to a dispensary might pose an irritating hurdle for people with solid finances, it’s an overwhelming barrier for those on limited budgets. One of my elderly patients spent $200 in one month just to travel to a dispensary.
As a result, some of my patients skip the licensed dispensaries and buy cheaper, more readily available street marijuana through unregulated sources. Purchasing street marijuana is not only illegal, but it also means that I do not know exactly what patients have purchased, how they are using it, or how it may affect their health.
Other patients with chronic pain continue to take opioids, as there are few barriers to buying prescription opioid medications. Most patients spend nothing, or a small copay, to fill a prescription for opioids, and they can pay with a credit card.
The experience of the patients in our clinic points to a new mandate: make it easier and more affordable for all qualified individuals to obtain medical cannabis. It’s time to advocate for a new federal classification for cannabis, so insurance companies can cover it, just as they cover the costs of drugs to treat cancer, diabetes, and other diseases. At the same time, we need to consider subsidies or discounts for low-income patients and expand the number of licensed dispensaries for medical cannabis.
Without a more equitable system, this new health care disparity will become entrenched alongside so many others, leaving many of those most in need of medical cannabis without access to it.
Julia Arnsten, M.D., is chief of the Division of General Internal Medicine at Albert Einstein College of Medicine and Montefiore Health System, and a registered practitioner with the New York State Medical Marijuana Program.