Changes in suicide in California from 2017 to 2021: a population-based study.

BackgroundSuicide is a major public health problem with immediate and long-term effects on individuals, families, and communities. In 2020 and 2021, stressors wrought by the COVID-19 pandemic, stay-at-home mandates, economic turmoil, social unrest, and growing inequality likely modified risk for self-harm. The coinciding surge in firearm purchasing may have increased risk for firearm suicide. In this study, we examined changes in counts and rates of suicide in California across sociodemographic groups during the first two years of the COVID-19 pandemic relative to prior years.MethodsWe used California-wide death data to summarize suicide and firearm suicide across race/ethnicity, age, education, gender, and urbanicity. We compared case counts and rates in 2020 and 2021 with 2017-2019 averages.ResultsSuicide decreased overall in 2020 (4123 deaths; 10.5 per 100,000) and 2021 (4104; 10.4 per 100,000), compared to pre-pandemic (4484; 11.4 per 100,000). The decrease in counts was driven largely by males, white, and middle-aged Californians. Conversely, Black Californians and young people (age 10 to 19) experienced increased burden and rates of suicide. Firearm suicide also decreased following the onset of the pandemic, but relatively less than overall suicide; as a result, the proportion of suicides that involved a firearm increased (from 36.1% pre-pandemic to 37.6% in 2020 and 38.1% in 2021). Females, people aged 20 to 29, and Black Californians had the largest increase in the likelihood of using a firearm in suicide following the onset of the pandemic. The proportion of suicides that involved a firearm in 2020 and 2021 decreased in rural areas compared to prior years, while there were modest increases in urban areas.ConclusionsThe COVID-19 pandemic and co-occurring stressors coincided with heterogeneous changes in risk of suicide across the California population. Marginalized racial groups and younger people experienced increased risk for suicide, particularly involving a firearm. Public health intervention and policy action are necessary to prevent fatal self-harm injuries and reduce related inequities

Handgun purchasing characteristics and firearm suicide risk: a nested case-control study.

BACKGROUND:Firearms are the most lethal method of suicide and account for approximately half of all suicide deaths nationwide. We describe associations between firearm purchasing characteristics and firearm suicide. METHODS:Data on all legal handgun transactions in California from 1996 to 2015 were obtained from the California Department of Justice Dealer's Record of Sale database. Handgun purchasers were linked to mortality data to identify those who died between 1996 and 2015. To account for variation in timing and duration of observation time, analyses were stratified by birth cohort. The primary analysis focused on those aged 21-25 in 1996. A secondary analysis tested associations among those aged 50-54 in 1996. Using incidence density sampling, purchasers who died by firearm suicide (cases) were each gender-matched to 5 purchasers (controls) who remained at risk at the case's time of death. We examined the characteristics of purchasers and transactions, focusing on the transaction closest in time to the case's death. Data were analyzed with conditional logistic regression. RESULTS:There were 390 firearm suicides among the younger cohort and 512 firearm suicides among the older cohort. Across both cohorts, older age at first purchase and the purchase of a revolver were associated with greater risk of firearm suicide. For example, among the younger cohort, those who purchased a revolver versus semiautomatic pistol had 1.78 times the risk of firearm suicide (95% CI 1.32, 2.40) in multivariable models. Other associations varied across cohorts, suggesting cohort or age effects in purchasing patterns. CONCLUSIONS:Findings add to the evidence on firearm suicide risk and may help inform prevention strategies and future research

Association of medical conditions and firearm suicide among legal handgun purchasers in California: a case-control study.

BackgroundSuicide is a pressing public health problem, and firearm owners are at especially elevated risk. Certain health conditions are markers of suicide risk, but more research is needed on clinical risk markers for suicide among firearm owners specifically. Our goal was to examine associations of emergency department and inpatient hospital visits for behavioral and physical health conditions with firearm suicide among handgun purchasers.MethodsThis was a case-control study of 5415 legal handgun purchasers in California who died between January 1, 2008, and December 31, 2013. Cases were firearm suicide decedents; controls were motor vehicle crash decedents. Exposures were emergency department and hospital visits for six categories of health diagnoses in the 3 years prior to death. To account for selection bias due to deceased controls, we used probabilistic quantitative bias analysis to generate bias-adjusted estimates.ResultsThere were 3862 firearm suicide decedents and 1553 motor vehicle crash decedents. In multivariable models, suicidal ideation/attempt (OR 4.92; 95% CI 3.27-7.40), mental illness (OR 1.97; 95% CI 1.60-2.43), drug use disorder (OR 1.40; 95% CI 1.05-1.88), pain (OR 1.34; 95% CI 1.07-1.69), and alcohol use disorder (OR 1.29; 95% CI 1.01-1.65) were associated with higher odds of firearm suicide. When adjusting for all conditions simultaneously, only the associations for suicidal ideation/attempt and mental illness remained significant. Quantitative bias analysis indicated that observed associations were generally biased downward. For example, the bias-adjusted OR for suicidal ideation/attempt was 8.39 (95% simulation interval 5.46-13.04), almost twice that of the observed OR.ConclusionsDiagnoses for behavioral health conditions were markers for firearm suicide risk among handgun purchasers, even for conservative estimates that did not adjust for selection bias. Encounters with the healthcare system may provide opportunities to identify firearm owners at high risk of suicide

Assessment of Extreme Risk Protection Order Use in California From 2016 to 2019.

ImportanceA total of 19 states and the District of Columbia now have extreme risk protection order (ERPO) or similar policies, and others are considering them; however, little research exists describing their use.ObjectiveTo characterize early use of California's ERPO policy by providing the first aggregate, statewide description of ERPOs, individuals subject to them, and petitioners.Design, setting, and participantsThis cross-sectional study analyzed 1076 respondents to ERPOs recorded in the California Department of Justice California Restraining and Protective Order System from 2016 to 2019. Descriptive analyses of orders issued between January 1, 2016, and December 31, 2019 in California were performed, and univariate Moran I was calculated to examine county-level spatial autocorrelation of the policy's use.Main outcomes and measuresThe primary study outcomes included the characteristics of ERPO respondents (demographic characteristics), petitioners (law enforcement vs family or household members), and orders (type and service) as well as temporal and spatial variation in policy use during the first 4 years of implementation.ResultsOf 1076 respondents during the study period, most were men (985 [91.5%]) and white individuals (637 [59.2%]), with a mean age of 41.8 years (range, 14 to 98 years). A law enforcement officer was the petitioner in 1038 cases (96.5%). The number of respondents increased during the study period from 70 in 2016 to 700 in 2019, and there was substantial county-level variation in ERPO use (ranging from 0 to 354 respondents), with significant spatial clustering in counts of ERPO respondents among neighboring counties (observed Moran I, 0.18, mean [SD] Moran I from reference distribution, -0.01 (0.05); z value, 3.58; P = .004).Conclusions and relevanceThis study, among the first to describe the early utilization of an ERPO or similar policy, found a substantial increase in the use of ERPOs in California from 2016 to 2019. These results could inform policy makers and other stakeholders involved in policy implementation and outreach in California and elsewhere. Similar studies in other states would be useful to understand variation

The origins of California's gun violence restraining order law: a case study using Kingdon's multiple streams framework.

BackgroundFirearm violence is a major public health problem in the United States, yet most states lack a mechanism to temporarily remove firearms from individuals who are at high and imminent risk of harming themselves or others and are not otherwise prohibited. Extreme risk protection order (ERPO) laws are intended to close this gap. The current study examines the passage of California's gun violence restraining order (GVRO) bill using Kingdon's multiple streams framework.MethodsThis study was based on an analysis of interview data from six key informants involved in the passage of the GVRO legislation.ResultsFindings indicate policy entrepreneurs framed the problem and designed the policy to target individuals at behavioral risk of imminent firearm violence. Policy entrepreneurs comprised an integrated policy network that engaged in a lengthy period of collaboration and bargained with interest groups to yield a bill that satisfied diverse concerns.ConclusionsThis case study may inform efforts in other states to pass ERPO policies and other firearm safety laws

Experiences of violence in daily life among adults in California: a population-representative survey.

BackgroundResearch on violence exposure emphasizes discrete acute events such as direct and witnessed victimization. Little is known about the broad range of experiences of violence (EVs) in daily life. This study assesses the prevalence and patterns of distribution of 6 EVs in an adult general population.MethodsCalifornia state-representative survey administered online (English and Spanish), July 14-27, 2020. Adult (age ≥ 18 years) California resident members of the Ipsos KnowledgePanel were eligible to participate. Two EVs concerned community environments: (1) the occurrence of gunshots and shootings in the neighborhood and (2) encounters with sidewalk memorials where violent deaths occurred. Four concerned social networks: direct personal knowledge of individuals who (1) had purposefully been shot by someone else or (2) had purposefully shot themselves, and direct personal knowledge of individuals whom respondents perceived to be at risk of violence, either (3) to another person or (4) to themselves. Main outcome measures, expressed as weighted percentages with 95% confidence intervals (CIs), were the prevalence and extent (or dose) of each EV and of EVs in combination and associations between EVs and respondents' sociodemographic characteristics and firearm ownership status.ResultsOf 2870 respondents (57% completion rate), 52.3% (95% CI 49.5-55.0%) were female; mean [SD] age was 47.9 [16.9] years. Nearly two-thirds (64.6%, 95% CI 61.9-67.3%) reported at least 1 EV; 11.4% (95% CI 9.7-13.2%) reported 3 or more. Gender was not associated with the prevalence of any experience. Non-owners of firearms who lived with owners reported more extensive EVs through social networks than did firearm owners or non-owners in households without firearms. Knowledge of people who had been shot by others was most common among Black respondents, 31.0% (95% CI 20.9-43.3%) of whom knew 2 or more such persons. Knowledge of people who had shot themselves was greatest among respondents aged ≥ 60 years, but knowledge of persons perceived to be at risk of violence to themselves was greatest among respondents aged 18-29 years.Conclusions and relevanceExperiences of violence in daily life are widespread. They occur in sociodemographic patterns that differ from those for direct victimization and suggest new opportunities for research and intervention

Racial Disparities in Opioid Analgesia Administration Among Adult Emergency Department Patients with Abdominal Pain

Introduction: Racial disparities in pain management have been reported among emergency department (ED) patients. In this study we evaluated the association between patients’ self-identified race/ethnicity and the administration of opioid analgesia among ED patients with abdominal pain, the most common chief complaint for ED presentations in the United States. Methods: This was a retrospective cohort study of adult (age ≥18 years) patients who presented to the ED of a single center with abdominal pain from January 1, 2019–December 31, 2020. We collected demographic and clinical information, including patients’ race and ethnicity, from the electronic health record. The primary outcome was the ED administration of any opioid analgesic (binary). Secondary outcomes included the administration of non-opioid analgesia (binary) and administration of any analgesia (binary). We used logistic regression models to estimate odds ratios (OR) of the association between a patient’s race/ethnicity and analgesia administration. Covariates included age, sex, initial pain score, Emergency Severity Index, and ED visits in the prior 30 days. Subgroup analyses were performed in non-pregnant patients, those who underwent any imaging study, were admitted to the hospital, and who underwent surgery within 24 hours of ED arrival. Results: We studied 7,367 patients: 45% (3,314) were non-Hispanic (NH) White; 28% (2,092) were Hispanic/Latinx; 19% (1,384) were NH Black, and 8% (577) were Asian. Overall, 44% (3,207) of patients received opioid analgesia. In multivariable regression models, non-White patients were less likely to receive opioid analgesia compared with White patients (OR 0.73, 95% CI 0.65-0.83 for Hispanic/Latinx patients; OR 0.62, 95% CI 0.54-0.72 for Black patients; and OR 0.64, 95% CI 0.52-0.78 for Asian patients). Black patients were also less likely to receive non-opioid analgesia, and Black and Hispanic/Latinx patients were less likely than White patients to receive any analgesia. The associations were similar across subgroups; however, the association was attenuated among patients who underwent surgery within 24 hours of ED arrival.  Conclusion: Hispanic/Latinx, Black, and Asian patients were significantly less likely to receive opioid analgesia than White patients when presenting to the ED with abdominal pain. Black patients were also less likely than White patients to receive non-opioid analgesia

Implementation and perceived effectiveness of gun violence restraining orders in California: A qualitative evaluation.

BackgroundUptake of gun violence restraining orders (GVROs), which temporarily prohibit the possession and purchase of firearms and ammunition from individuals at particularly high risk of harming themselves or others with a firearm, has been slow and heterogenous across California. Insights into the implementation process and perceived effectiveness of the law could guide implementation in California and the many states that have enacted or are considering enacting such a law.MethodsWe conducted 21 semi-structured interviews with 27 key informants, including judges, law enforcement officers, city and district attorneys, policy experts, and firearm violence researchers. Analysis of transcripts was guided by grounded theory and the Consolidated Framework for Implementation Research (CFIR).FindingsThe following constructs emerged within 4 CFIR domains as salient features of implementation: 1) implementation characteristics: risk of violence, cost, and adaptability; 2) outer setting: interagency coordination and local firearm ideology; 3) inner setting: readiness for implementation and law enforcement firearm culture; and 4) implementation process: planning and engaging with those involved in implementation. Key informants perceived the law to be effective, particularly for preventing firearm suicide, but agreed that more research was needed. While most indicated that the law resulted in positive outcomes, concerns about the potential for class- and race-based inequities were also raised.ConclusionsImplementation of the GVRO law in California was hampered by a lack of funding to support local proactive implementation efforts. This resulted in ad hoc policies and procedures, leading to inconsistent practices and widespread confusion among those responsible for implementation. In states that have not begun implementation, we recommend dedicating funding for implementation and creating local procedures statewide prior to the law's rollout. In California, recommendations include providing training on the GVRO law-including an explication of agency-specific roles, responsibilities, and procedures-to officers, city attorneys, and civil court judges

Extreme Risk Protection Orders Intended to Prevent Mass Shootings: A Case Series.

Urgent, individualized interventions to reduce firearm access, such as extreme risk protection orders (ERPOs, colloquially known as "red flag" orders), provide a rapid, focused response when risk for imminent firearm violence is high. Studies to date suggest such interventions are most commonly used to prevent suicide and are effective. Authorizing legislation has often been enacted after public mass shootings but, to our knowledge, there have been only 2 reported cases of ERPO use in efforts to prevent mass shootings. California enacted the nation's first ERPO statute, which took effect in January 2016. The authors are evaluating that statute's implementation and effectiveness and are seeking to obtain court records for all 414 cases occurring in 2016 to 2018. Based on 159 records received thus far, this article presents an aggregate summary and individual histories for a preliminary series of 21 cases in which ERPOs were used in efforts to prevent mass shootings. Most subjects were male and non-Hispanic white; the mean age was 35 years. Most subjects made explicit threats and owned firearms. Four cases arose primarily in relation to medical or mental health conditions, and such conditions were noted in 4 others. Fifty-two firearms were recovered. As of early August 2019, none of the threatened shootings had occurred, and no other homicides or suicides by persons subject to the orders were identified. It is impossible to know whether violence would have occurred had ERPOs not been issued, and the authors make no claim of a causal relationship. Nonetheless, the cases suggest that this urgent, individualized intervention can play a role in efforts to prevent mass shootings, in health care settings and elsewhere. Further evaluation would be helpful