The impact of spikes in handgun acquisitions on firearm-related harms.

BackgroundResearch has documented sharp and short-lived increases in firearm acquisitions immediately following high-profile mass shootings and specific elections, increasing exposure to firearms at the community level. We exploit cross-city variation in the estimated number of excess handgun acquisitions in California following the 2012 presidential election and the Sandy Hook school shooting 5 weeks later to assess whether the additional handguns were associated with increases in the rate of firearm-related harms at the city level.MethodsWe use a two-stage modeling approach. First, we estimate excess handguns as the difference between actual handgun acquisitions, as recorded in California's Dealer Record of Sales, and expected acquisitions, as predicted by a seasonal autoregressive integrated moving-average (SARIMA) time series model. We use Poisson regression models to estimate the effect of city-level excess handgun purchasing on city-level changes in rates of firearm mortality and injury.ResultsWe estimate there were 36,142 excess handguns acquired in California in the 11 weeks following the election (95% prediction interval: 22,780 to 49,505); the Sandy Hook shooting occurred in week 6. We find city-level purchasing spikes were associated with higher rates of firearm injury in the 52 weeks post-election: a relative rate of 1.044 firearm injuries for each excess handgun per 1,000 people (95% CI: 1.000 to 1.089). This amounts to approximately 290 (95% CI: 0 to 616) additional firearm injuries (roughly a 4% increase) in California over the year. We do not detect statistically significant associations for shorter time windows or for firearm mortality.ConclusionThis study provides evidence for an association between excess handgun acquisitions following high-profile events and firearm injury at the community level. This suggests that even marginal increases in handgun prevalence may be impactful

Associations between implementation of Project Lazarus and opioid analgesic dispensing and buprenorphine utilization in North Carolina, 2009–2014

Background Project Lazarus (PL) is a seven-strategy, community-coalition-based intervention designed to reduce opioid overdose and dependence. The seven strategies include: community education, provider education, hospital emergency department policy change, diversion control, support programs for patients with pain, naloxone policies, and addiction treatment expansion. PL was originally developed in Wilkes County, NC. It was made available to all counties in North Carolina starting in March 2013 with funding of up to $34,400 per county per year. We examined the association between PL implementation and 1) overall dispensing rate of opioid analgesics, and 2) utilization of buprenorphine. Buprenorphine is often used in connection with medication assisted treatment (MAT) for opioid dependence. Methods Observational interrupted time series analysis of 100 counties over 2009–2014 (n = 7200 county-months) in North Carolina. The intervention period was March 2013–December 2014. 74 of 100 counties implemented the intervention. Exposure data sources comprised process surveys, training records, Prescription Drug Monitoring Program (PDMP) data, and methadone treatment program quality data. Outcomes were PDMP-derived counts of opioid prescriptions and buprenorphine patients. Incidence Rate Ratios were estimated with adjusted GEE Poisson regression models of all seven PL strategies. Results In adjusted models, diversion control efforts were positively associated with increased dispensing of opioid analgesics (IRR: 1.06; 95% CI: 1.03, 1.09). None of the other PL strategies were associated with reduced prescribing of opioid analgesics. Support programs for patients with pain were associated with a non-significant decrease in buprenorphine utilization (IRR: 0.93; 95% CI: 0.85, 1.02), but addiction treatment expansion efforts were associated with no change in buprenorphine utilization (IRR: 0.98; 95% CI: 0.91, 1.06). Conclusions Implementation of PL strategies did not appreciably reduce opioid dispensing and did not increase buprenorphine utilization. These results are consistent with previous findings of limited impact of PL strategies on overdose morbidity and mortality. Future studies should analyze the uptake of MAT using a more expansive view of institutional barriers, treating community coalition activity around MAT as an effect modifier

Incidence, Distribution, and Lethality of Firearm Injuries in California From 2005 to 2015.

ImportanceLittle is known about nonfatal firearm injuries in the United States, and national estimates based on emergency department samples may not be accurate.ObjectiveTo describe the incidence and distribution of nonfatal firearm injuries and estimate case fatality ratios (CFRs) for firearm injuries by external cause of injury code within California overall and by race/ethnicity, including an assessment of trends over time and geographic variation within the state.Design, setting, and participantsThis serial cross-sectional study used complete statewide data for firearm-related mortality, emergency department visits, and hospitalizations among California residents from January 1, 2005, through December 31, 2015, to analyze incidence, distribution, and CFRs of firearm injury. Data were analyzed from 2018 to 2019.ExposuresAll individuals in California with a firearm injury based on International Classification of Diseases, Ninth Revision or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes were included.Main outcomes and measuresCounts and rates of nonfatal firearm injuries overall and stratified by external cause, sex, and race/ethnicity; total and clinical CFRs. Clinical CFR was calculated based on individuals treated in emergency departments or hospitals.ResultsOver the study period, there were 81 085 firearm-related emergency department visits and hospitalizations among individuals with a mean (SD) age of 27.5 (11.9) years, 72 567 (89.6%) of whom were men. Nonfatal firearm injuries in California decreased by 38.1% between 2005 and 2015, driven by a 46.4% decrease in assaultive injuries. Self-inflicted injuries and unintentional injuries remained relatively stable. The overall CFR for firearm injuries increased from 27.6% in 2005 to 32.2% in 2015 for a relative increase of 20.7%, while the clinical CFR remained stable between 7.0% and 9.0%.Conclusions and relevanceThese findings suggest that although the number of firearm injuries has decreased in California, the lethality of these injuries has not. Similar studies from other states could provide more information about these trends nationwide

The impact of spikes in handgun acquisitions on firearm-related harms.

BackgroundResearch has documented sharp and short-lived increases in firearm acquisitions immediately following high-profile mass shootings and specific elections, increasing exposure to firearms at the community level. We exploit cross-city variation in the estimated number of excess handgun acquisitions in California following the 2012 presidential election and the Sandy Hook school shooting 5 weeks later to assess whether the additional handguns were associated with increases in the rate of firearm-related harms at the city level.MethodsWe use a two-stage modeling approach. First, we estimate excess handguns as the difference between actual handgun acquisitions, as recorded in California's Dealer Record of Sales, and expected acquisitions, as predicted by a seasonal autoregressive integrated moving-average (SARIMA) time series model. We use Poisson regression models to estimate the effect of city-level excess handgun purchasing on city-level changes in rates of firearm mortality and injury.ResultsWe estimate there were 36,142 excess handguns acquired in California in the 11 weeks following the election (95% prediction interval: 22,780 to 49,505); the Sandy Hook shooting occurred in week 6. We find city-level purchasing spikes were associated with higher rates of firearm injury in the 52 weeks post-election: a relative rate of 1.044 firearm injuries for each excess handgun per 1,000 people (95% CI: 1.000 to 1.089). This amounts to approximately 290 (95% CI: 0 to 616) additional firearm injuries (roughly a 4% increase) in California over the year. We do not detect statistically significant associations for shorter time windows or for firearm mortality.ConclusionThis study provides evidence for an association between excess handgun acquisitions following high-profile events and firearm injury at the community level. This suggests that even marginal increases in handgun prevalence may be impactful

Associations between implementation of Project Lazarus and opioid analgesic dispensing and buprenorphine utilization in North Carolina, 2009–2014

Abstract Background Project Lazarus (PL) is a seven-strategy, community-coalition-based intervention designed to reduce opioid overdose and dependence. The seven strategies include: community education, provider education, hospital emergency department policy change, diversion control, support programs for patients with pain, naloxone policies, and addiction treatment expansion. PL was originally developed in Wilkes County, NC. It was made available to all counties in North Carolina starting in March 2013 with funding of up to $34,400 per county per year. We examined the association between PL implementation and 1) overall dispensing rate of opioid analgesics, and 2) utilization of buprenorphine. Buprenorphine is often used in connection with medication assisted treatment (MAT) for opioid dependence. Methods Observational interrupted time series analysis of 100 counties over 2009–2014 (n = 7200 county-months) in North Carolina. The intervention period was March 2013–December 2014. 74 of 100 counties implemented the intervention. Exposure data sources comprised process surveys, training records, Prescription Drug Monitoring Program (PDMP) data, and methadone treatment program quality data. Outcomes were PDMP-derived counts of opioid prescriptions and buprenorphine patients. Incidence Rate Ratios were estimated with adjusted GEE Poisson regression models of all seven PL strategies. Results In adjusted models, diversion control efforts were positively associated with increased dispensing of opioid analgesics (IRR: 1.06; 95% CI: 1.03, 1.09). None of the other PL strategies were associated with reduced prescribing of opioid analgesics. Support programs for patients with pain were associated with a non-significant decrease in buprenorphine utilization (IRR: 0.93; 95% CI: 0.85, 1.02), but addiction treatment expansion efforts were associated with no change in buprenorphine utilization (IRR: 0.98; 95% CI: 0.91, 1.06). Conclusions Implementation of PL strategies did not appreciably reduce opioid dispensing and did not increase buprenorphine utilization. These results are consistent with previous findings of limited impact of PL strategies on overdose morbidity and mortality. Future studies should analyze the uptake of MAT using a more expansive view of institutional barriers, treating community coalition activity around MAT as an effect modifier

Unemployment and Crime in US Cities During the Coronavirus Pandemic.

Unemployment and violence both increased during the coronavirus pandemic in the United States (US), but no studies to our knowledge have examined their association. Using data for 16 US cities from January 2018 to July 2020, we estimated the association between acute changes in unemployment during the coronavirus pandemic and violent and acquisitive crime. We used negative binomial regression models and parametric g-computation to estimate average differences in crime incidents if the highest and lowest levels of unemployment observed in each city had been sustained across the exposure period (March-July 2020), compared with observed unemployment in each city-month. During the pandemic, the percentage of the adult population who were unemployed was 8.1 percentage points higher than expected, on average. Increases in unemployment were associated with increases in firearm violence and homicide. For example, we estimated an average increase of 3.3 firearm violence incidents (95% CI: - 0.2, 6.7) and 2.0 homicides (95% CI: - 0.2, 3.9) per city-month from March to July 2020 if all cities experienced their highest versus observed level of unemployment. There was no association between unemployment and aggravated assault or any acquisitive crime. Findings suggest that the sharp rise in unemployment during the pandemic may have contributed to increases in firearm violence and homicide, but not other crime. Additional research is needed on mechanisms of association, generalizability, and modifying factors

Firearm purchasing and firearm violence during the coronavirus pandemic in the United States: a cross-sectional study.

BackgroundFirearm violence is a significant public health problem in the United States. A surge in firearm purchasing following the onset of the coronavirus pandemic may have contributed to an increase in firearm violence. We sought to estimate the state-level association between firearm purchasing and interpersonal firearm violence during the pandemic.MethodsCross-sectional study of the 48 contiguous states and the District of Columbia from January 2018 through July 2020. Data were obtained from the National Instant Criminal Background Check System (a proxy for firearm purchasing) and the Gun Violence Archive. Using negative binomial regression models, we estimated the association between cumulative excess firearm purchases in March through July 2020 (measured as the difference between observed rates and those expected from autoregressive integrated moving average models) and injuries (including nonfatal and fatal) from intentional, interpersonal firearm violence (non-domestic and domestic violence).ResultsWe estimated that there were 4.3 million excess firearm purchases nationally from March through July 2020 and a total of 4075 more firearm injuries than expected from April through July. We found no relationship between state-level excess purchasing and non-domestic firearm violence, e.g., each excess purchase per 100 population was associated with a rate ratio (RR) of firearm injury from non-domestic violence of 0.76 (95% CI: 0.50-1.02) in April; 0.99 (95% CI: 0.72-1.25) in May; 1.10 (95% CI: 0.93-1.32) in June; and 0.98 (95% CI: 0.85-1.12) in July. Excess firearm purchasing within states was associated with an increase in firearm injuries from domestic violence in April (RR: 2.60; 95% CI: 1.32-5.93) and May (RR: 1.79; 95% CI: 1.19-2.91), though estimates were sensitive to model specification.ConclusionsNationwide, firearm purchasing and firearm violence increased substantially during the first months of the coronavirus pandemic. At the state level, the magnitude of the increase in purchasing was not associated with the magnitude of the increase in firearm violence. Increases in purchasing may have contributed to additional firearm injuries from domestic violence in April and May. Results suggest much of the rise in firearm violence during our study period was attributable to other factors, indicating a need for additional research

Physical Distancing, Violence, and Crime in US Cities during the Coronavirus Pandemic.

Violent crime increased and most property crime decreased in many United States (US) cities during the coronavirus pandemic. Using negative binomial regressions, we examined the association between physical distancing (a central coronavirus containment strategy) and crime within 16 large cities (in 12 US states and the District of Columbia) through July 2020. Physical distancing was measured with aggregated smartphone data and defined as the average change in the percentage of the population staying completely at home. Outcome data were obtained from the Gun Violence Archive and city open data portals. In multivariable models, increases in the percentage of the population staying home were associated with decreases in reported incidents of aggravated assault, interpersonal firearm violence, theft, rape, and robbery, and increases in arson, burglary, and motor vehicle theft. Results suggest that changes in the frequency of interpersonal interactions affected crime during the coronavirus pandemic. More research is needed on the specificity of these assocations and their underlying mechanisms

Association of Prior Convictions for Driving Under the Influence With Risk of Subsequent Arrest for Violent Crimes Among Handgun Purchasers.

ImportanceAlcohol use is a risk factor for firearm-related violence, and firearm owners are more likely than others to report risky drinking behaviors.ObjectiveTo study the association between prior convictions for driving under the influence (DUI) and risk of subsequent arrest for violent crimes among handgun purchasers.DesignIn this retrospective, longitudinal cohort study, 79 678 individuals were followed up from their first handgun purchase in 2001 through 2013. The study cohort included all legally authorized handgun purchasers in California aged 21 to 49 years at the time of purchase in 2001. Individuals were identified using the California Department of Justice (CA DOJ) Dealer's Record of Sale (DROS) database, which retains information on all legal handgun transfers in the state.ExposuresThe primary exposure was DUI conviction prior to the first handgun purchase in 2001, as recorded in the CA DOJ Criminal History Information System.Main outcomes and measuresPrespecified outcomes included arrests for violent crimes listed in the Crime Index published by the Federal Bureau of Investigation (murder, rape, robbery, and aggravated assault), firearm-related violent crimes, and any violent crimes.ResultsOf the study population (N=79 678), 91.0% were males and 68.9% were white individuals; the median age was 34 (range, 21-49) years. The analytic sample for multivariable models included 78 878 purchasers after exclusions. Compared with purchasers who had no prior criminal history, those with prior DUI convictions and no other criminal history were at increased risk of arrest for a Crime Index-listed violent crime (adjusted hazard ratio [AHR], 2.6; 95% CI, 1.7-4.1), a firearm-related violent crime (AHR, 2.8; 95% CI, 1.3-6.4), and any violent crime (AHR, 3.3; 95% CI, 2.4-4.5). Among purchasers with a history of arrests or convictions for crimes other than DUI, associations specifically with DUI conviction remained.Conclusions and relevanceThis study's findings suggest that prior DUI convictions may be associated with the risk of subsequent violence, including firearm-related violence, among legal purchasers of handguns. Although the magnitude was diminished, the risk associated with DUI conviction remained elevated even among those with a history of arrests or convictions for crimes of other types