Where We Stand
Section: Public Health
Policy: Firearm Injury Prevention Task Force Report

Appendix K


1. Adoption of the following principles, with integration into Where We Stand, A Guide to OMA Policy Statements:

  1. Firearm injury is a public health epidemic that affects all ages, races, and socioeconomic levels. The sequelae from firearm injury threatens the welfare and well-being of all Oregonians. Methods to reduce firearm-related injuries and deaths should be broad and comprehensive.
  2. Gun ownership is valued by a substantial percentage of the population, including a portion of healthcare providers. Laws and policies to reduce firearm-related deaths and injuries should be evidence-based and consistent with the constitutional right of firearm ownership.
  3. Deaths and injuries related to firearms are preventable. Firearm-related deaths and injuries can be reduced in Oregon.
  4. Effective screening, assessment, counseling, and restricted access to firearms among high-risk individuals can preserve life and function.
  5. Physicians and other healthcare providers have a responsibility to take action, lead public health efforts, and inform evidence-based legislation to reduce firearm injury and death.
  6. Physicians and other healthcare providers must have unrestricted ability to discuss firearm safety, screen at-risk patients, and counsel patients and their families to avoid firearm injury.
  7. Addressing key factors, including mental health crises, domestic violence, and alcohol misuse, are important aspects of reducing firearm injury.
  8. Changing how violence is portrayed in society is a crucial step towards reducing firearm injury. The depiction of violence in the media, television, movies, and other aspects of society desensitizes the public and contributes to a culture of violence.
  9. Expanded efforts in clinician training and public education about firearm injury are needed. These educational efforts should cut across all demographics and ages, representing all populations affected by firearm injury.
  10. Research and research funding are needed to guide evidence-based methods to reduce firearm injury and deaths. Data collection, data sharing, and other efforts related to firearm research should be strongly supported across communities, agencies, and organizations.

 

2. That the OMA support the following strategies to reduce firearm-related injuries and deaths in Oregon

  • Universal background checks for all individuals purchasing firearms, including closure of loopholes that circumvent the screening process
  • Ammunition background checks
  • Mandatory waiting periods for firearm purchase
  • Restricted access to firearms among persons at risk of harming themselves or others
  • Restricted access to firearms among persons with a history of alcohol misuse, including alcohol-related legal infractions
  • A rigorous permit-to-purchase system for all firearm purchases
  • Safe firearm storage laws (unloaded, gun safes, and gun locks)
  • Child access protection laws to protect children from unsafe storage of firearms
  • Firearm identification with owners (e.g., ballistic fingerprinting or micro stamping)
  • Mandatory reporting of lost or stolen firearms
  • Prohibition of firearm purchase or possession by persons with a domestic violence restraining order
  • Restricted access of firearms for persons convicted of violent misdemeanors
  • Ban on semi-automatic assault weapons, large capacity magazines, and other devices designed for rapid killing capacity
  • Restriction of all products intended to prevent firearm detection or tracing (e.g., 3-dimensional printing for firearms)
  • Informed and effective clinician assessment of patients at risk of self-harm, including those with mental health crises and alcohol abuse
  • Increased capacity and patient access to mental health treatment in Oregon
  • Development of an evidence-based firearm curriculum, up-to-date resources, current statistics, and methods for implementing firearm-related counseling by health care providers
  • Formal integration of firearm injury education into medical training programs, including schools and residency programs
  • Promotion of ongoing Continuing Medication Education opportunities that follow an evidence-based curriculum
  • Alignment of education efforts toward reducing firearm injury with OMA partners, stakeholders, and related healthcare organizations
  • Development of partnerships with other states and organizations to promote congruity between state firearm laws and data sharing for firearm research

 

 3. That the following report be adopted as an appendix in Where We Stand

Background

Worldwide, the United States is second only to Brazil in total number of firearm deaths per year.1 The U.S. is also second in the age-adjusted rate of firearm suicide and is a leader in the age-adjusted rate of firearm homicide among industrialized nations.1,2 Two thirds of firearm-related deaths in the U.S. are due to suicide, with one third from homicide, and a small number from accidents.2 While mass killings in public places represent a small percentage of all firearm-related deaths,2 these events receive widespread media coverage and have changed the way Americans interact with one another. Active shooter safety drills are now routinely practiced in schools, hospitals, malls, and other settings.

The age-adjusted firearm fatality rate in Oregon is higher than the national average, as is the percent of firearm deaths due to suicide (82.1%).3 From 2010 to 2014, 2,280 Oregonians died from firearms, about one person per day.4 Guns are also commonly implicated in intimate partner violence. From 2003 to 2012, 256 people in Oregon were killed due to intimate partner violence, the majority of which were women and involved firearms.5 Firearm-related death and injury remain at epidemic levels nationally and in Oregon, representing preventable death and disability.

Understanding the magnitude, severity, and potential solutions to public health problems requires data and research. However, there have been broad, systematic efforts to suppress firearm research in the U.S. In 1996, a congressional appropriations bill was passed that prohibited the Centers for Disease Control and Prevention from funding research related to gun control, with subsequent extension to other federal agencies, including the National Institutes of Health.6,7 In 2003, Congress imposed restrictions on sharing information about guns used in crimes, which prevented access to key electronic data sources. More recently, a provision inserted into the Affordable Care Act forbade federal health programs from collecting or disclosing information about firearm ownership. As a result of these efforts, firearm research has received only 1.6% of predicted research funding and 4.5% of predicted publications, relative to its mortality burden.8 Intentionally preventing research on firearms essentially permits preventable deaths and injuries from firearms to continue.

To address these concerns, the Oregon Medical Association (OMA) approved development of a Firearm Injury Prevention Task Force in June 2018. Healthcare providers were selected from around the state, representing a range of perspectives, including those of gun owners. The Task Force met monthly, researched the evidence base, and developed a set of recommendations based on the best available evidence. This document includes a list of guiding principles, summary of Task Force recommendations, and detailed reports from each of the four workgroups (suicide; provider education; access and storage; and regulations and oversight). The recommendations are synergistic with one another. That is, implementation of multiple recommendations (rather than just one or two) is likely to have a more profound effect on reducing morbidity and mortality related to firearms, while respecting constitutional rights. Some legislative recommendations have already been implemented in Oregon (e.g., restricted firearm access for persons with a domestic violence restraining order, extreme risk protection order), but are included here for completeness and to affirm their protective benefit.  

 

Suicide and Firearms

Suicide is the most common cause of firearm-related fatalities nationally and in Oregon.2,3 While 62% of firearm fatalities are due to suicide in the U.S., they represent 82% in Oregon.3 In 2016, there were 513 firearm-related deaths in Oregon, most of which were from suicide. Regions in the U.S. with high suicide rates tend to be more closely aligned to the proportion of homes with firearms than to rates of mental illness.9 It is also clear that mental illness is not a risk factor for violence, but is a major risk factor for suicide.10 Access to firearms increases suicide attempt lethality by increasing the likelihood that suicide attempts will involve guns.11 The risk of completed suicide is also dramatically higher among persons with previous self-harm events involving firearms.12

Reducing Firearm Access During Times of Elevated Risk

The majority of suicidal crises are impulsive and fleeting,13 often lasting less than one hour,14 providing a narrow window to intervene. The ready availability of a lethal method affects its use, particularly for firearms.15 Recent purchase of a handgun has been strongly associated with suicide, beginning within one week of purchase.16,17 The case fatality rate of firearm-related suicide attempts is the highest of all methods.18 Therefore, interventions that delay the availability of firearms during suicidal crises are critical to reducing suicide-related deaths.19 Reductions in household firearm ownership have also been associated with reductions in suicide, including those involving children.20 Mandatory waiting periods for firearm purchases are associated with a reduction in firearm-related suicides, particularly among persons 55 and older21 and waiting periods specific to handguns.22 Oregon currently has no waiting period for gun purchase.

Alcohol and Suicide

Alcohol misuse is a common risk factor in firearm-related suicide.23 Alcohol increases impulsivity, which is a pivotal factor in suicide attempts. Acute and chronic alcohol misuse is associated with increased risk of interpersonal and self-directed firearm violence,23,24 providing a modifiable target for reducing such violence. Restrictions to firearm ownership among individuals who misuse alcohol (e.g., alcohol-related legal infractions) have been implemented in 37 states as a strategy for reducing firearm-related violence,23 though not in Oregon.

Legislative Strategies to Reduce Firearm-related Suicide

Laws that reduce firearm-related suicide generally involve limiting access to firearms during periods of impulsivity associated with suicidal thoughts. Examples of such legislative efforts include: universal background checks;25-29 ammunition background checks;28 mandatory waiting periods for purchase;21,22 restricting firearm access for persons with alcohol-related legal infractions or hospitalizations;23 permit-to-purchase laws for handguns;29,30 requirement of gun locks to store handguns;27 and methods to identify firearms with their owners (e.g., ballistic fingerprinting or microstamping).28 Oregon currently has an “extreme risk protection order”, which allows a court-ordered moratorium on purchasing or possessing a firearm among persons in danger of harming themselves or others. Oregon also requires background checks for purchases, including private party sales (although there are ways to circumvent this process). However, there are no Oregon laws for permit-to-purchase, safe storage, background checks for ammunition, or methods to link firearms with owners.

The Task Force recommends:

  1. Informed and effective clinician assessment of patients at risk of self-harm, including those with mental health and/or alcohol abuse;
  2. Increased capacity and patient access to mental health treatment in Oregon;
  3. Universal background checks, with closure of loopholes that circumvent this process;
  4. Ammunition background checks;
  5. Mandatory waiting periods for firearm purchase;
  6. Restricted access to firearms among persons at risk of harming themselves or others;
  7. Restricted access to firearms among persons with a history of alcohol misuse, including alcohol-related legal infractions;
  8. A rigorous permit-to-purchase system for all firearm purchases;
  9. Requirement for safe firearm storage (unloaded, gun safes, and gun locks); and
  10. Firearm identification with owners (e.g. ballistic fingerprinting or micro stamping).

 

Clinician Education and Firearms

Clinicians receive little training in methods to reduce firearm violence, including how to discuss firearm injury prevention with patients and families and calling upon current firearm laws to protect patients. While more research is needed to identify the most effective methods for screening and intervention, there are multiple sources of educational materials to educate and train clinicians.

Screening and Counseling by Healthcare Providers

The majority of firearm-related deaths in Oregon are from suicide,3 thus educational efforts should target screening for depression, suicidality, alcohol misuse, and counseling on safe storage. A comprehensive review of 72 articles concludes that providers “rarely” screen or counsel patients and families about firearm safety, even among high-risk patients.31 However, interventions targeted at healthcare providers can increase rates of firearm safety screening, counseling, and safe storage for high-risk patient groups.31 Also, patients and families are generally open to such screening and counseling.31 Seventy five percent of parents believe their child’s pediatrician should ask about safe firearm storage, which is similar among gun owners and non-owners.32 Importantly, talking to patients and families can change behavior around firearms. Discussing gun safety, providing a brochure, and a gun lock, increased the rate of safe gun storage when compared with a control group.33,34 Screening for cognitive impairment in the context of firearm safety is another potentially important focus for providers.35

Educating Healthcare Providers

Clinicians play a unique and vital role in screening and counseling patients at risk for firearm injury. It is important that all providers are knowledgeable about firearm-related state and federal laws, and are comfortable discussing these topics with patients and their families. For example, Oregon clinicians should be familiar with Oregon firearm laws related to domestic violence and the extreme risk protection order.

Developing a Firearm Curriculum for Healthcare Providers

An evidence-based educational curriculum for providers on firearm injury prevention should include description of risk factors for gun violence, methods for discussing ways to reduce firearm injuries, safe storage, and relevant state and federal laws. Existing curricula could be adapted by the OMA to help educate clinicians on these topics, including integration to medical training programs and continuing medical education requirements. Better training in identifying high-risk situations and reducing patient risk will increase clinician confidence and effectiveness in eliminating firearm injuries.

The Task Force recommends:

  1. Development of an evidence-based firearm curriculum, up-to-date resources, current statistics, and methods for implementing firearm-related counseling by Oregon healthcare providers;
  2. Formal integration of firearm injury education into medical training programs, including schools and residency programs in Oregon;
  3. Promotion of ongoing Continuing Medication Education opportunities that follow an evidence-based curriculum; and
  4. Alignment of educational efforts on eliminating firearm injury with OMA partners and other national and statewide healthcare organizations.

 

Access and Storage

Unrestricted access to firearms can result in preventable harm and death. Loaded and unlocked guns increase the number of preventable injuries and deaths related to firearms, particularly among high-risk persons. The National Rifle Association states “firearm education and safety is paramount…to promote the safe handling, use and storage of firearms.”36

Safe Storage

Recent purchase of a handgun has been associated with an increased risk of violent death.16,17 Safe storage is an important aspect of firearm safety because most guns used for self-harm or unintentional injuries originate from the home of the victim, a friend, or relative.37 A case-control study found that storage of locked and unloaded guns, plus locked ammunition stored in a separate location each have a protective effect.38 Relative to firearms that were unlocked and loaded, those stored locked and unloaded were 84% less likely to be involved in a shooting.38 Oregon does not legally require gun owners to lock or securely store guns when not in use.

Child Access Protection Laws

According to a 2018 study, 4.6 million children live in a household with at least one unlocked and loaded firearm, representing 7% of all children in the U.S.39 This proportion varies considerably across states.40 Safe storage is critically important for children because 89% of unintentional pediatric firearm injuries occur in the home.41 Incidents where children have unintentionally shot other children are often related to finding a gun unlocked.42 Storing household guns as locked, unloaded, and separate from ammunition is associated with significant reductions in the risk of unintentional and self-inflicted firearm injuries and deaths in children.43 Child Access Prevention (CAP) laws hold gun owners accountable for the safe storage of firearms, imposing liability for failing to take preventative measures against guns falling into the hands of children. Strong CAP laws are associated with a 30% reduction in pediatric firearm injuries, with even greater risk reduction against self-inflicted and unintentional injuries.43 However, there is large variability in these laws across states.43 CAP laws generally specify criminal liability for persons who negligently store firearms where minors could gain access, even when the firearm is unloaded. Some states specify civil liability for damages resulting from the discharge of a firearm stored negligently when a minor gains access, or the requirement that all firearms be stored with a locking device. Oregon has no CAP laws.

Impact of Physician Counseling on Safe Storage

There is a positive impact on behavior following physician counseling about firearms. In a case-control study of over 1,200 patients who received either verbal counseling about safe storage or verbal counseling plus written information, 58% of participants made a change in safe gun storage compared with 33% of the control group.34 The effectiveness of counseling was further increased by providing concurrent written material.34

Stolen Guns

Gun theft is common in the U.S., with approximately 380,000 guns stolen each year following legal purchase.44 This situation creates an ongoing source of weapons, some of which may be used for violence. The mass shooting at the Oregon Clackamas Town Center in 2012 was committed using a stolen gun. Oregon law does not mandate that gun owners promptly report when their firearms have been stolen. The lack of regulation around stolen guns allows for lack of accountability in firearm-related injuries.

Intimate Partner Violence Involving Firearms

Intimate partner homicide rates are higher in regions with greater access to and less restrictions on firearms.45 From 2003 to 2012, 256 people in Oregon were killed due to intimate partner violence, 82% of whom were women.5 Firearms are a common mechanism for death from intimate partner violence, which also frequently involves alcohol or substance use by perpetrators.5 In 2016, 45% of female homicide victims in Oregon were killed by an intimate partner.46 Prohibition of firearm purchase or possession for persons with a domestic violence restraining order is associated with a 10-19% reduction in intimate partner homicides.47,48 Current law in Oregon restricts firearms from persons with a domestic violence restraining order.

The Task Force recommends:

  1. Safe firearm storage laws to reduce injuries and deaths from firearms;
  2. Mandatory reporting of lost or stolen firearms;
  3. Prohibition of purchase and possession of firearms by persons with a domestic violence restraining order; and
  4. Child access protection laws to protect children from unsafe storage of firearms, including gun owner legal responsibility for discharge of a firearm stored negligently.

 

Regulation and Oversight

History of Federal Gun Regulation in the United States

While there are federal regulations on firearms, these regulations have become more permissive over time. The National Firearms Act of 1934 imposed a statutory excise tax on the manufacture and transfer of certain firearms and mandated the registration of those firearms. The Federal Firearms Act of 1938 imposed a federal license requirement on gun manufacturers, importers, and persons in the business of selling firearms, plus a requirement to maintain customer records and prohibition of sale to certain classes of persons, such as convicted felons. The Gun Control Act of 1968 replaced the National Firearms Act and Federal Firearms Act. This act regulates interstate transfer of firearms, requires imprinted serial numbers on firearms, and has record-keeping requirements to allow law enforcement to trace firearm transfers. Federal regulations require individuals purchasing a firearm to sign a form stating they are not convicted felons or otherwise disqualified under federal law, but there is no obligation for the gun dealer to verify this claim. Firearm transfers by private gun owners are not regulated. The Firearm Owners Protection Act of 1986 revised and weakened many provisions of the Gun Control Act, including language that the government would not maintain a database of firearm purchases. The Brady Handgun Violence Prevention Act of 1993 mandated federal background checks on firearm purchasers through the National Instant Criminal Background Check System maintained by the FBI. However, firearm transfers by unlicensed private sellers that are "not engaged in the business" of dealing firearms are not subject to the Brady Act and other methods have been developed to circumvent this law. The Protection of Lawful Commerce in Arms Act of 2005 protects firearms manufacturers and dealers from being held liable when crimes have been committed with their products. Several federal laws, including the federal ban on semi-automatic assault weapons and high-capacity magazines, have expired or been repealed.

Restricting Firearm Possession by Violent Criminals

Restricting firearm possession by violent criminals has the potential to reduce future gun-related violence and crime. Despite federal regulations, legal gun ownership by offenders imprisoned for crimes committed with a firearm remains common, yet stricter state gun laws could potentially reduce repeat firearm-related offenses.49 Domestic violence restraining order provisions that prevent persons from buying or possessing firearms have been shown to reduce intimate partner homicide rates.47,48 In a study that compared individuals arrested but not convicted of a felony (able to purchase firearms) with individuals convicted of felonies (unable to purchase firearms), those approved to purchase a handgun were 21% more likely to be subsequently arrested for a crime involving a gun and 24% more likely to be arrested for a violent crime.50  Handgun purchasers with a prior misdemeanor are also at increased risk for committing future firearm-related crimes.51 Laws denying handgun purchase to persons previously convicted of violent misdemeanors reduces new gun and/or violent crimes.52

Legislation Preventing Access to Firearms by Criminals

Federal firearm laws are principally aimed at keeping firearms out of the hands of criminals and basic record-keeping to assist law enforcement with investigation of firearm-related crimes. Increasingly, evidence suggests that federal firearm laws are lax and easily circumvented by criminals, leaving more rigorous legislation up to individual states. Some states have enacted permit-to-purchase policies to better regulate access to firearms. The conditions of these policies vary from an online application to fingerprinting and photography. States with more rigorous registration and licensing systems have a lower rate of purchased guns being recovered in crimes.53 States with rigorous permit-to-purchase systems, comprehensive background checks, and mandatory theft/loss reporting curtail diversion of guns to criminals, but these benefits can be offset by an influx of guns from states with weak regulations.54 The repeal of a permit-to-purchase law in Missouri was associated with a 25% increase in firearm homicide rates, despite no change in non-firearm homicides.55 Banning high-risk handguns can also reduce the use of these weapons among criminals.56 Oregon does not have a permit-to-purchase law, mandatory reporting of lost guns, or linkage of firearms to their owners. 

Semi-Automatic Assault Weapons and Large Capacity Magazines

Starting in 1994, there was a federal law banning semi-automatic assault weapons and large capacity magazines in the U.S., which was allowed to expire in 2004. During the ban, gun crimes involving these weapons decreased, but this decrease was offset by the use of other guns equipped with large capacity magazines exempted from the ban.57 Semi-automatic assault weapons are used in a minority of gun crimes (although their use as crime guns has been increasing since expiration of the ban), but they are used in the majority of firearm-related mass murders.58 In 1996, Australia passed major gun law reforms, including a ban on semi-automatic weapons in response to a mass shooting incident. For 20 years following this ban, there have been no mass firearm killings in Australia.59 While firearm-based mass shootings constitute a small percentage of all firearm-related deaths,2 these events have had a profound effect on society, including children. The integration of active shooter drills in U.S. schools is now routine. While bans on semi-automatic weapons may not have a notable overall effect on gun crime,57 they have a large effect on reducing the incidence of mass shootings.59,60 Oregon has no laws related to semi-automatic assault weapons or large capacity magazines.

The Task Force recommends:

  1. Prohibition of firearm purchase or possession by persons with a domestic violence restraining order;
  2. Restricted access of firearms for persons convicted of violent misdemeanors;
  3. Mandatory reporting of lost or stolen firearms;
  4. Universal background checks for all individuals purchasing firearms, including closure of loopholes that circumvent the screening process;
  5. A rigorous permit-to-purchase system for all firearm purchases;
  6. Ban on semi-automatic assault weapons, large capacity magazines, and other devices designed for rapid killing capacity;
  7. Restriction of all products intended to prevent firearm detection or tracing (e.g., 3-dimensional printing for firearms); and
  8. Development of partnerships with other states and organizations to promote congruity between state firearm laws and data sharing for firearm research.

 

Task Force Members

Thomas Cooney, MD (Internal Medicine; Portland)

Maxine Dexter, MD (Pulmonary and Critical Care; Portland)

Kathryn Glassberg, MD (Internal Medicine; Clackamas)

David Lehrfeld, MD (Emergency Medicine; Portland)

Kristen Massimino, MD* (Surgical Oncology; Portland)

Michael McCaskill, MD (Emergency Medicine; Medford)

Craig Newgard, MD, MPH* (Emergency Medicine; Portland)

Lisa Reynolds, MD (Pediatrics; Portland)

Audrey Tran, BS (OHSU medical student; Portland)

Jennifer Watters, MD (Trauma Surgery; Bend)

Craig Zarling, MD (Psychiatry; Portland)

*Co-Chairs

 

 

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