Firearm Violence Prevention and the Physician:

Transcription

1 Firearm Violence Prevention and the Physician: A PUBLIC HEALTH APPROACH July 28, 2017

2 The United States (U.S.) continues to struggle with an epidemic of firearm violence. Not only are physicians in a unique position to assess risk, provide education and change behaviors related to gun violence, they may also address this issue more broadly as a consumer safety and public health issue. In 2015, there were 34,997 deaths in the United States that were caused by firearms, with firearm-related suicide deaths outnumbering firearm-related homicides by a large margin. Suicide was the tenth leading cause of death in 2015 and firearms accounted for almost half of those deaths, for which older white men were at the highest risk. 1, 2 Homicide is the leading cause of death for male and female African Americans aged years, and firearm-related homicide is highest among young African American men. 3 When combined, suicide and homicide were the fourth leading cause of years of potential life lost in the U.S. in 2015, and they accounted for the second and third leading causes of death, respectively, amongst adolescents and young adults. 4 Mass shootings account for a small percentage of the firearm violence deaths yet result in unnecessary morbidity and mortality and capture media and the publics attention. The economic burden of firearm death and injury is substantial, reaching $229 billion in aggregate costs and representing about 1.4% of U.S. gross domestic product. 5 In 2017, CMA convened an ad hoc Firearm Violence Prevention Committee ( Committee ) to perform a comprehensive review and analysis of the following materials as it relates to prevention of gun violence: (1) existing CMA policy, (2) other medical and health organization policy statements, (3) epidemiological data, and (4) current scientific research. Members of the Committee include: Shannon Udovic-Constant, MD (Chair), Amy Barnhorst, MD, Catherine Gutfreund, MD, Eric Hansen, MD, Donald Lyman, MD, John Maa, MD, Paul Phinney, MD, Andrew Fenton, MD, Zachary Wettstein, and Garen Wintemute, MD. Staff: Samantha Pellon, MPH, and Elishah Thompson. Position Statement The following position statement on the prevention of firearm violence, as recommended by the Committee was officially adopted by the CMA Board of Trustees on July 28, CMA recognizes that fundamentally, firearm violence is a human and civil rights matter; it violates the fundamental human right to life, liberty, and security of person - the right to live safely without fear in a free society. In heavily impacted communities, the ordinary activities of daily life are contorted as people seek to avoid victimization. Involvement is broader than is commonly recognized. While interpersonal violence involves primarily young men, with persons of color at highest risk, self-directed violence involves primarily older men, and risk is higher among white men than others. Violence against women is important, particularly where domestic violence is concerned. Mass shootings, though uncommon, are changing the character of American public life. There are important structural and cultural determinants of risk; not all risk is at the individual level. The consequences of firearm violence - for individuals directly affected, those around them, affected communities, and California at large are substantial. a. CMA declares firearm violence to be a public health and public safety problem with major direct and indirect negative effects at individual and community levels. b. CMA recognizes there are disproportionately high rates of firearm violence in low-income communities and communities of color, and supports efforts to decrease this by mitigating the structural causes of disparities in firearm violence. c. CMA supports decreasing the frequent depiction of violence in the media as it may contribute to desensitization towards violence and to a culture of violence in our society. 2. California physicians have a responsibility to take action on the prevention of firearm-related injuries and deaths. a. As with other public health issues, physicians have a unique responsibility as trusted public health CMA Position Statement on Firearm Violence Prevention Page 1 of 8

3 figures to respond to the harms associated with firearm violence, both as individual clinicians and as community advocates. b. Through their role in routine screening and assessment, physicians are able to counsel and educate patients about firearm safety and storage, including best practices to reduce injuries, deaths, and psychological trauma related to firearm use. Particular care should be given to individuals in risk categories such as a history of alcohol or substance abuse, history of violence, and risk of harm to self or others. c. CMA opposes any policies, regulations or legislation that restricts physicians ability to initiate discussions about firearm safety issues with patients. d. Expanded education and training are needed to improve clinician familiarity with the benefits and risks of firearm ownership, safety practices, and communication with patients about firearm violence. Medical schools and residency programs should incorporate firearm violence prevention into their academic curricula. California-specific resources such as continuing medical education modules, toolkits, patient education handouts, and clinical intervention information would help to address this practice gap. 3. CMA opposes the suppression of firearm research that has stripped federal and state funding for data surveillance, research and analysis, which has prevented the advancement of evidence-based policies as benefitting other major public health issues. a. CMA supports restoration of funding for firearm research and data surveillance proportional to its public health impact which will, in turn, help support and drive evidence-based policy solutions. b. CMA supports the systematic collection of firearm-related morbidity and mortality data using comprehensive national and state databases, and supports elimination of barriers to access of this data for research purposes. 4. CMA is concerned that the focus on people with mental illness as perpetrators of interpersonal and community violence distracts from the fact that their mental illness is a much stronger risk factor for suicide than for violence against others, and that people with mental illness are much more likely to be victims of violence than perpetrators of violence. a. Greater attention and resources should be spent upon reducing the risk of suicide by improving access to mental health treatment and addressing the subset of individuals with mental illness who may be at risk of harming themselves or others. b. Physicians should be trained to recognize warning signs and respond to patients who may present with a mental illness, and may be at risk of harming themselves or others. This includes being aware of the laws that may necessitate reporting obligations as well as understanding which clinical interventions might lead to a patient becoming prohibited from owning a firearm or having a firearm in their possession being temporarily removed. 5. CMA recognizes that California has been a state leader in addressing federal statutory and regulatory gaps in firearm policy. CMA supports California s strong legal and regulatory protections related to firearms, and commits to working with the American Medical Association and others to improve federal policy in that regard. a. CMA recognizes that gun ownership is valued by many members of the public, and agrees that laws and regulations related to firearm violence should be consistent with the constitutional right establishing individual ownership of firearms under the Second Amendment of the Bill of Rights. CMA Position Statement on Firearm Violence Prevention Page 2 of 8

4 b. CMA supports the appropriate regulation and taxation of firearm and ammunition purchases, and that such items be subject to legal and regulatory protections in regard to design, sale or transfer, possession and storage. c. CMA supports the establishment of a universal background check system and the successful completion of a use and safety course for all persons buying or otherwise taking ownership of a firearm or purchasing ammunition. d. CMA supports a requirement for firearm owners to report the theft or loss of a firearm within 72 hours of becoming aware of the loss. e. CMA acknowledges evidence indicating that individuals with a history of alcohol or substance abuse, domestic violence, suicidal ideation or other physical harm to self or others are at increased risk for firearm violence, and supports appropriate restriction of access to firearms for such individuals. f. CMA supports appropriate limitation or ban on possession of firearms and ammunition with features designed to increase their rapid killing capacity, or are particularly lethal. g. CMA acknowledges that waiting periods prior to firearm purchases may be effective in reducing suicide deaths attributable to firearms. h. CMA supports local authority for cities and counties to enact laws more restrictive than those at state or federal levels as they relate to the sale, possession, taxation, transfer and other aspects of commerce related to firearms and ammunition. i. CMA specifically recommends firearm safety practices including: storing firearms unloaded and in locked position in a separate location from ammunition, as a means of reducing unintentional and self-inflicted firearm injuries, in particular among children and teenagers. j. CMA acknowledges a constantly changing landscape related to firearm violence, and recommends revisiting the issue at appropriate, frequent intervals over the next decade. 6. CMA supports targeted public education campaigns on firearm violence and its prevention as a way to make positive impacts on public opinion, and cost-effectively provide key information to important audiences. The targeted outcome of a public education campaign is to improve public understanding of the risks associated with firearms and to enlist community partners in the effort to reduce morbidity and mortality from firearms. 7. CMA supports a population-based, public health approach directed towards firearm violence, with emphasis on forms of firearm violence that have disproportionate societal impact, including the following: higher incidence of firearm violence in low-income communities and communities of color; firearm violence by and against law enforcement, in particular the use of lethal force; firearm violence by and against individuals with mental illness; and public mass shootings. Policy Discussion Prior to adoption of the current comprehensive position statement, CMA policy concerning firearms was under two broad categories: firearm regulation and a public health approach to firearm violence. Firearm Regulation. Under this broad category, CMA supports certain limitations on firearm access, a strong regulatory structure, and criminal penalty enhancements if there is a crime committed with a firearm. CMA supports efforts to ensure people with a pattern of substance abuse are not able to easily access firearms, and prohibits ownership or unsupervised use of handguns by individuals under the age of 21. CMA has also endorsed background checks for handgun purchases, the mandatory successful completion of a firearm use and safety CMA Position Statement on Firearm Violence Prevention Page 3 of 8

5 course prior to purchasing, owning or using a firearm and ammunition in California, a statewide tax and licensing structure for firearms and ammunition sales, and consumer product protections regarding access, safety, and design. Public Health Approach to Firearm Violence. CMA also has extensive policy supporting a physician s right to counsel patients of firearm risk, and incorporate as routine inquiry, discussions around firearm safety and storage as a preventive health measure. CMA recognizes that the proliferation of guns to be a major public health problem and significant contributing factor to the broader issue of violence and fear. CMA also supports funding for firearm research and a comprehensive data surveillance system to accurately track firearm morbidity and mortality. CMA has supported a strong licensing and regulatory structure in terms of firearm and ammunition sales, and restricting access to dangerous firearms, such as assault weapons. CMA is also very supportive of a physician s right to counsel patients regarding firearm risks, and firearm violence data surveillance. CMA s policy development related to firearms had been largely reactive to events that drew statewide attention and condemnation, and changed the perception of firearm violence in California. For example, following the 1989 school shooting at the Cleveland Elementary School in Stockton, the state reacted by passing an assault weapons ban; CMA adopted a policy that same year supporting a ban of sales of high clip capacity semiautomatic weapons. Many of CMA s positions on firearms were developed in the mid-1990s in a reactive capacity, and since then, further evidence and research on this topic has emerged. Over this same period, several other physician organizations have studied this issue and released updated, comprehensive policy statements, including the American Academy of Pediatrics, American College of Physicians, American Psychiatry Association and the National Physicians Alliance. The Firearm Violence Prevention Committee analyzed these statements and identified several areas of consensus. After comparing these areas of consensus with gaps in CMA policy, and examining supporting epidemiological data and scientific research, the Committee identified several priority areas for inclusion in a comprehensive statement of principles, which would replace existing CMA policy related to firearm violence. They include the following, in no particular order: Health Care Interventions. The Committee felt strongly that our policy needed a call to action for physicians and the medical community to lead and speak out on prevention of firearm violence. Similar to other public health issues that physicians have championed, there exists a responsibility as trusted community figures to be responsive to the harms associated with firearm violence, both as individual clinicians and as community advocates. Additionally, through their role in routine screening and assessment, physicians are able to counsel and educate their patients about the risks and behaviors known to be associated with the leading causes of morbidity and mortality. Physicians and other primary health care professionals are trained to instruct patients and parents in matters of preventable injuries such as water safety, car seats and seat belt use, poison prevention, and can do the same with firearms. While CMA policy opposes gag rules that would prohibit physician discussions of firearm risk, and supports counseling as routine inquiry, the Committee wanted to make this a point of emphasis, as providers rarely screen or counsel their patients in such despite evidence that physician counseling about firearm storage can improve safety practices among patients. 6 While many barriers exist, including time and concern about patients being resistant to these conversations, the largest barrier is clinician unfamiliarity with the benefits and risks of firearm ownership and safety prac- CMA Position Statement on Firearm Violence Prevention Page 4 of 8

6 tices, and how to approach these conversations with patients. 7 As a result, the Committee felt it important to emphasize the need for physician education and training in firearms injury prevention, and that academic curriculum in medical schools, residency programs, and continuing medical education (CME) programs should incorporate firearm violence prevention into their resources and training. Further, the Committee also recommended that the development of California-specific physician and patient resources be developed to address this practice gap, identifying recent relevant materials that the Massachusetts Medical Society released in partnership with the Massachusetts Attorney General. 8 For example, the Massachusetts provider brochure offers guidance on when to engage with patients on this topic and how to approach these conversations, followed by state-specific legal requirements that may necessitate health care provider reports to law enforcement. Access to Firearms by High-Risk Individuals. While CMA policy does support efforts to ensure people with a pattern of substance abuse are not able to easily access firearms, the Committee felt that a more current statement regarding the risk factors that may make some individuals more prone to firearm violence is needed. The Committee reviewed research that identifies certain risk factors that may make people more likely to misuse firearms or serve as strong predictors for future violence. These include the following: Alcohol Abuse: Evidence indicates that alcohol use and firearm violence are strongly interrelated, and a history of alcohol abuse is a risk factor for both homicides and suicides. One study estimated that in an average month, 8.9 to 11.7 million firearm owners binge drink and for men, deaths from alcohol-related firearm violence equal those from alcohol-related motor vehicle crashes. 9 Despite this, there is an absence of federal and/or state policies that restrict access to firearms by individuals with a history of alcohol abuse. Violence: Prior violent crimes or a history of violence perpetration is also a strong risk factor for future violence. 10 Additionally, recent research indicates that hospitalization for a firearm-related injury is associated with a heightened risk for subsequent violent victimization or crime perpetration. 11 Drug Abuse: While the evidence is more limited, drug abuse is another risk factor for increased interpersonal violence and suicide, although the degree of risk may be dependent upon the specific drug. 12 The Committee also wanted to make a special distinction for mental illness, which is commonly misunderstood in terms of its association with firearm violence. Partly because of the portrayal of mental illness in the aftermath of mass shootings, there is a misplaced belief that mental illness is a causal factor of these incidents and firearm violence in general. In reality, mass shootings only account for about 1% of all violent encounters. Serious mental illness is a minor risk factor for interpersonal violence, although specific mental illness diagnoses may be more predictive of violence. 13 In particular, mental illness is strongly linked to self-directed violence, with 47% to 74% of suicides attributed to mental disorders. 14 As a result, the Committee cautioned against broadly categorizing those with mental illness as dangerous individuals, but rather, directed CMA policy to address the prevention and treatment of the subset of individuals with mental illness who may be at risk of harming themselves or others. In support of this goal, the Committee felt that there should be more education against the stigma of mental illness and interpersonal violence, and emphasis upon shifting public discourse and resources to the link between mental illness and suicides. Lastly, the Committee also discussed a recent California law which allows concerned family members or law enforcement officers to petition a court for a Gun Violence Restraining Order (GVRO). In situations where there is sufficient evidence for a judge to believe that an individual poses a danger to self or others, the GVRO will temporarily prohibit the individual from purchasing or possessing firearms or ammunition and allow law enforcement to remove any firearms or ammunition already in the individual s possession. There was some thought that CMA Position Statement on Firearm Violence Prevention Page 5 of 8

7 this law may not be well-known or well-understood, particularly by clinicians, and could be more widely shared as initial data has returned positive results. Regulation and Taxation of Firearms and Ammunition. CMA policy supports certain elements that regulate firearm purchases, such as background checks for handgun sales and satisfactory completion of a safety training course prior to purchase. The Committee wanted to be mindful that gun ownership is valued by the public, and that such regulation should be consistent with the Supreme Court ruling establishing individual ownership of firearms as a constitutional right under the Second Amendment of the Bill of Rights. The Committee recognized that California has been a state leader in terms of filling the federal statutory and regulatory gaps, but acknowledged that this landscape is constantly changing and CMA should revisit these issues at frequent intervals over the next decade. With that said, the Committee did support the use of background checks and limitations upon possession of firearms and ammunition that have features designed to increase their rapid killing capacity, or are particularly lethal. While there is limited evidence that waiting periods can reduce homicides, the Committee discussed the link between suicides, impulsivity and use of firearms: approximately 90% of individuals who have survived a suicide attempt do not subsequently die in suicides, and a person who attempts suicide by a method other than a firearm is more likely to live than a person who uses a firearm. 15, 16 As a result, the Committee acknowledges that waiting periods may reduce suicide deaths by firearms. CMA supports design safety standards for handguns and child-proof safety locks, however, the Committee opted to include broader language in support of consumer regulations concerning access, design and safety of firearms, in general. CMA policy also lacks a statement specific as to the safe storage of firearms in the home, including the use of locking devices, to help prevent unintentional deaths. The presence of unlocked guns in the home increases the risk of both unintentional gun injuries and intentional shootings. 17 Alternatively, keeping a gun locked, unloaded, storing ammunition locked, and in a separate location are each associated with a protective effect towards reducing the risk of unintentional and self-inflicted firearm injuries among children and teenagers where guns are stored. Firearm Violence Data and Research. While CMA policy very clearly supports firearm violence data surveillance, the Committee believed a more forceful statement that reflects the increased need to remove impediments that prevent or delay access to data, and encourage funding for firearm research, analysis and data surveillance. This, in turn, can help support and drive evidence-based policy solutions. Public Education Campaign. Similar to other public education campaigns, the Committee emphasized that firearm violence could be best addressed by changing cultural and social attitudes via targeted educational efforts. For example, in the early 1990 s, the California Wellness Foundation invested in a campaign to educate policymakers, community leaders and the general public about the effects of handgun violence and possible prevention approaches as part of its Violence Prevention Initiative. Public Health Approach Directed towards Forms of Firearm Violence. The Committee envisions a population-based epidemiologic approach to firearm violence that utilizes lessons learned from other public health successes. For example, California s comprehensive tobacco control program has been very successful by adhering to a denormalization strategy aimed at reducing the social acceptability of tobacco use and exposure to secondhand smoke in California communities. This has included implementing effective population-based tobacco control interventions, such as tobacco price increases, high-impact anti-tobacco mass media campaigns, and comprehensive smoke-free policies. A similar public health model can be applied towards firearm violence, with emphasis on the forms of firearm violence that have disproportionate societal impact, including: CMA Position Statement on Firearm Violence Prevention Page 6 of 8

8 Health Disparities. Interpersonal violence predominately affects younger people and people of color, and it can shatter families, communities, and jeopardize the health and safety of the public. There are disproportionately high rates of community violence in low-income communities and communities of color, and disparity contributes heavily to overall health inequities. Among 10 to 24 year-olds, homicide is the leading cause of death for African Americans; the second leading cause of death for Latinos/Hispanics; and the third leading cause of death for American Indians and Alaskan Natives. 18 Research indicates violence can progress or exacerbate a broad range of chronic illnesses, and can impact healthful eating and active living. The health consequences for those who are victimized or exposed to violence are severe and can include serious physical injuries, post-traumatic stress syndrome, depression, anxiety, substance abuse, and other longer-term health problems. 19 Violence, and the fear of it, can undermine attempts to improve nutrition and activity levels, thereby aggravating existing illnesses and increasing the risk for onset of disease. 20 Violence is preventable, and CMA policy supports a public health approach as the most effective model in addressing violence. While many violence prevention strategies involve place-based comprehensive and coordinated plans across multi-sectors (e.g., law enforcement, community groups, social service, and education), the Committee believes that the policy statement should emphasize a public health approach to firearm violence prevention as a means of increasing health equity. Violence by and Against Law Enforcement. In recent years, public attention around the use of lethal force by law enforcement has heightened following several high-profile shootings of unarmed men and youth by police. These concerns over the use of lethal force, with links to racial and social inequities and use of force against the mentally ill, have resulted in civil unrest and public calls for increased attention within public health. The use of lethal force also reflects the risks inherent in policing and the duty by law enforcement to mitigate immediate danger to the public. In fact, the number of law enforcement officers shot and killed in the line of duty increased by 10 percent in 2016 with 135 officer fatalities over the 123 who died in the line of duty in While research on lethal force fatalities by law enforcement is limited, a recent study examined the characteristics and circumstances of such deaths from 2009 and 2012 and found the following: victims were majority white (52%) but disproportionately black (32%) with a fatality rate 2.8 times higher among blacks than whites. Most victims were reported to be armed (83%); however, black victims were more likely to be unarmed (14.8%) than white (9.4%) or Hispanic (5.8%) victims. Further, about 22% of lethal force cases involved those with mental health issues. 22 Because the data and research is still evolving and is somewhat limited, the Committee thought it was too early to take a position on this issue, but agreed that the policy statement should mention the gravity of lethal force violence, concerns around racial/ethnic inequities and its affect on community health and wellness. Mental Illness. The Committee wanted to emphasize a population-based approach to the prevention of mental illness as a key component of public health engagement with mental health. Given that mental illness is strongly linked with self-directed violence, a public health approach that promotes early identification, intervention, collaboration and family engagement can help protect against such occurrences. Public Mass Shootings. While mass shootings only account for about 1% of all violent encounters, the Committee recognizes the large impact of such events in causing great damage and stoke fear among families, communities, and our society at-large. CMA Position Statement on Firearm Violence Prevention Page 7 of 8

9 Endnotes 1 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). Accessed May 5, Wintemute GJ, Betz ME, Ranney ML. Yes, You Can: Physicians, Patients, and Firearms. Ann Intern Med. 2016;165: doi: /M Ibid 4 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). Accessed May 5, Wintemute GJ. Presentation at Firearm Violence Prevention Committee Meeting, April 19, Roszko PJD, Ameli J, Carter PM, et al. Clinician attitudes, screening practices, and interventions to reduce firearm-related injury. Epidemiol Rev. 2016;38: Wintemute GJ, Betz ME, Ranney ML. Yes, You Can: Physicians, Patients, and Firearms. Ann Intern Med. 2016;165: doi: /M Massachusetts Medical Society and Massachusetts Attorney General. April Care/Health_Topics/Firearm%20Guidance%20for%20Providers%20final.pdf 9 Garen J. Wintemute, Alcohol misuse, firearm violence perpetration, and public policy in the United States, Preventive Medicine, Volume 79, October 2015, Pages 15-21, ISSN , 10 Wintemute GJ, Wright MA, Drake CM, Beaumont JJ. Subsequent Criminal Activity Among Violent Misdemeanants Who Seek to Purchase HandgunsRisk Factors and Effectiveness of Denying Handgun Purchase. JAMA. 2001;285(8): doi: /jama Rowhani-Rahbar A, Zatzick D, Wang J, Mills BM, Simonetti JA, Fan MD, et al. Firearm-Related Hospitalization and Risk for Subsequent Violent Injury, Death, or Crime Perpetration: A Cohort Study. Ann Intern Med. 2015;162: doi: /M Emma E. McGinty, Seema Choksy, Garen J. Wintemute; The Relationship Between Controlled Substances and Violence. Epidemiol Rev 2016; 38 (1): doi: /epirev/mxv Wintemute GJ. Presentation at Firearm Violence Prevention Committee Meeting, April 19, Wintemute GJ, Betz ME, Ranney ML. Yes, You Can: Physicians, Patients, and Firearms. Ann Intern Med. 2016;165: doi: /M Matthew Miller et al., Suicide Mortality in the United States: The Importance of Attending to Method in Understanding Population-Level Disparities in the Burden of Suicide, 33 Ann. Rev. Pub. Health 393 (2012). 16 Matthew Miller et al., The Epidemiology of Case Fatality Rates for Suicide in the Northeast, 43 Annals Of Emergency Med. 723, 726 (2004). 17 David C. Grossman, Donald T. Reay & Stephanie A. Baker, Self-Inflicted and Unintentional Firearm Injuries Among Children and Adolescents: The Source of the Firearm, 153 Arch. Pediatr. Adolesc. Med. 875, 875 (Aug. 1999). 18 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Webbased Injury Statistics Query and Reporting System (WISQARS) [online]. Available from 19 Prevention Institute. Links between violence and chronic illnesses. May 2011, 20 Prevention Institute. Addressing the Intersection: Preventing Violence and Promoting Healthy Eating and Active Living. May 2010, 22 National Law Enforcement Memorial Officers Fund. Preliminary 2016 Law Enforcement Officer Fatalities Report. December DeGue, Sarah et al. Deaths Due to Use of Lethal Force by Law Enforcement. American Journal of Preventive Medicine, Volume 51, Issue 5, S173 - S187, CMA Position Statement on Firearm Violence Prevention Page 8 of 8