There were many interesting findings in our study. The main finding was that nearly 84% of those who responded to the questionnaire were CC. This rate is very high, and it raises the question of whether the responders of the questionnaire represent the whole community of the three fibromyalgia Facebook groups. A response rate of 14% to an Internet questionnaire is considered an accepted rate [13, 14], and the correlation between a paper-based survey and electronic survey was high in one study [13]. This may actually indicate that more than 80% of the total number (2,705) of patients in the fibromyalgia social media groups were consuming cannabis.

The rate of approval for MC licensing by the MCA was also relatively high (142/317, 45%) among the fibromyalgia participants in our study. However, it must be remembered that many of these patients likely had concurrent medical conditions that facilitated or were the main reason for approval. Unfortunately, the questionnaire did not include questions regarding specific diseases or conditions such as malignancy that the patients might also have, in the interest of improving compliance with the questionnaire. Licenses for MC use were issued by the MCA after an appeal in about 37% of the MC-licensed patients; among some, three appeals were required prior to approval. Therefore, appealing for MC licensing after refusal by the MCA is always recommended.

The mean quantity of cannabis consumed by all CC was nearly 1g per day, and nearly two-thirds of the patients licensed for MC reported that their supplied quantity was not sufficient. More than half (~55%) reported buying cannabis from the black market.

It must be remembered that the price of the supplied MC for licensed patients is fixed regardless of the quantity supplied, standing at about $120 a month, while those buying on the black market sometimes pay as high as $1,450 a month to get cannabis, figures that are quite high. These figures reflect the high demand for cannabis by fibromyalgia patients in our country.

Most of MC consumers used three or more species of cannabis. This indicates that one species of cannabis cannot suffice for the different complaints of the patients, such as pain, insomnia, anxiety, or lack of energy. Different species and different concentrations of tetrahydrocannabinol (THC) and cannabidiol (CBD) were needed to tackle these complaints. Unfortunately, we did not specifically document the concentration of THC or CBD in each species.

Most of the patients used unlicensed cannabis by smoking it mixed with tobacco, while those using MC smoked it without mixing it. Some used vaporization and some used oral oil drops. Vaporization appealed primarily to women who did not want to smoke, while cannabis oil drops were considered weak in terms of efficacy. Oil drops, however, had a long term effect and were usually used as a complement to smoking or vaporization. The other advantage of oil drop preparations of cannabis is the accurate measurement of both THC and CBD that patients eventually get.

As expected, a high percentage of patients (94%) reported pain relief; the impact on sleep, a major problem among fibromyalgia patients, was similar, making cannabis a versatile remedy. It also improved depression and anxiety, though in a lower percentage of patients. All these effects make cannabis very appealing to fibromyalgia patients.

Only 12% of all cannabis users in our study reported adverse effects, compared to 94% reporting adverse effects from other pain meds prior to cannabis use. Most cannabis-related adverse effects were mild and transient such as eye or throat irritation (data not shown). In addition, only 8% of cannabis users felt dependent on cannabis, as opposed to 66% feeling dependent on other pain meds. On the other hand, nearly 85% of the patients either completely stopped taking any other pain medications or reduced the dosage of other meds. This reflects the advantage of cannabis over other meds in alleviating pain in addition to its favorable effects on sleep and mood.

Eighty-one percent (81%) of the patients reported an improvement in their capacity to perform daily activities, and 64% reported going back to part- or even full-time jobs. These figures are very important to the patients personally, to their families, and to society in general. We could not find data in the literature about this issue among patients treated with cannabis for different indications. However, in a large study assessing the impact of cannabis as an illicit drug, a detrimental effect was found on employment and labor force [15].

Although the MCA explicitly explains that it is forbidden to drive under cannabis use, most patients do drive under the effect of cannabis, with only about 21% of licensed patients not driving at all under cannabis treatment. It could be that those patients who drive under the influence of cannabis feel focused enough to proceed with driving.

Although fibromyalgia is not listed among the medical conditions for social security liability, there is an increasing awareness by social security employees, and more and more patients are approved for disability benefits, although the percent of disability granted for these patients is still lower than the real physical and functional disabilities they face. Still, many patients are granted no social security disability, and the 51% figure in our study actually reflects total disability, mainly due to these patients' other diseases and medical conditions.

Eighty-nine percent (89%) of the patients do not keep their use of cannabis a secret but share this information with their close family members. This fact probably reflects the favorable social effect of cannabis enabling patients to spend more time with their family members rather than seeking isolation and the increased general awareness of this type of treatment in the country.

The results of our study should encourage both the Rheumatology Association in our country and the MCA to reconsider their stand on cannabis and include fibromyalgia among the indications for MC under certain restrictions.