April/May ‘23: Extreme Risk Protection Orders

Written by: Brianna Brooks (MS1-SMFP)

The views expressed in this piece are those of the author. They do not represent the official views of the University of Pittsburgh School of Medicine or the University of Pittsburgh. 

The threat of gun violence: 

 Guns are currently a leading cause of morbidity and mortality for all age groups. Recently there has been an unsettling increase in local and national gun violence. Due to mass shootings in the past weeks, communities have mourned those lost in Louisville, Dadeville, Waianae, Northridge, Newark, and Kansas City. Similar to national trends, 3 in 5 gun deaths in Pennsylvania are due to suicide. Many students and clinicians are concerned but unsure of what they can do to reduce the threat of gun violence to the health of patients, loved ones, and communities. Extreme Risk Protection Orders (ERPO) are allowing clinicians in some states to assist in the process of removing firearms from crisis situations. As more states adopt ERPO laws, evidence shows that many clinicians are unaware of what ERPO is (1). Additionally, only 20% of pediatric residents received medical training on talking to patients about firearm safety (2). 

About ERPO: 

ERPO otherwise known as “red flag laws” are temporary civil orders that allow concerned family members, law enforcement, school administrators, and clinicians to petition a court to remove firearms from people at risk of violence against themselves or others. Judges consider records of violent behavior and threats of violence when deciding to remove firearms from an individual's possession for up to one year until they can receive help. ERPO is a temporary and civil order designed to respect second amendment rights (7). Research shows ERPOs prevent gun deaths. In Connecticut, it was found that for every 10-20 orders issued, one suicide was prevented (3). In a survey of 21 cases in California where ERPO was implemented, no suicides or homicides later occurred (4). 

Assessment of clinicians as petitioners: 

Clinicians are well-positioned to make an impact on the epidemic of gun violence, and they should have access to a public health tool to prevent injury and death. Physicians commonly encounter patients in crisis and could use this knowledge to target ERPO to those at the greatest risk as an effective complement to lethal means counseling (7). Research shows that physicians are agreeable to the tool: 60% of physicians indicated they would likely file an ERPO for a patient (1). There is a need and a willingness for physicians to use ERPO but some implementation challenges remain.

Allowing clinicians to petition for ERPOs could label gun violence as a mental health problem when mental illness is not a significant predictor of violence (5). This idea perpetuates the stigma around mental health (5). Additionally, disclosing private medical information to a court could undermine trust and patient privacy outlined in the social contract of the profession and HIPAA (6). However, this type of disclosure would likely fall under the obligation to disclose information about an imminent threat to safety (6). The primary barrier cited by physicians is a lack of time to petition so a coordinator may be necessary for the feasibility of implementation (1).

Policy landscape: 

Last year, President Biden charged the Justice Department with publishing model legislation for states to adopt ERPO laws and advocated for a federal version of the law. As part of the Bipartisan Safer Communities Act that was signed into law in June 2022 after the Uvalde school shooting, states that create and implement ERPOs are eligible to receive federal grants. Previously, former President Trump called on states to pass ERPO laws to secure school safety. 

Currently, 19 states have ERPO laws including three states that allow clinicians to petition for an ERPO. Many states including Pennsylvania have introduced new legislation which names clinicians among eligible petitioners. 

What clinicians need to know:

As new gun violence legislation emerges, learn how ERPO can be implemented into physicians' practice with this Continuing Medical Education event “Extreme Risk Protection Orders What Clinicians Need to Know”. 

Conclusion:

ERPOs are one of many strategies that have shown promising evidence of the prevention of gun injuries and deaths in the U.S. Clinicians are not powerless to prevent the health consequences of guns. Emerging policy solutions like ERPO are allowing clinicians more effective tools to be part of the solution that makes gun violence abnormal in our society. 

1.     Frattaroli S, Hoops K, Irvin NA, et al. Assessment of physician self-reported knowledge and use of Maryland’s extreme risk protection order law. JAMA Netw Open. 2019;2(12):e1918037. https://doi.org/10.1001/jamanetworkopen.2019.18037. Accessed 4/17/2023. doi: 10.1001/jamanetworkopen.2019.18037.

2.     Hoops K, Crifasi C. Pediatric resident firearm-related anticipatory guidance: Why are we still not talking about guns? Prev Med. 2019;124:29-32. https://www.sciencedirect.com/science/article/pii/S0091743519301598. doi: 10.1016/j.ypmed.2019.04.020.0

3.     Swanson JW, Norko MA, Lin H, et al. Implementation and effectiveness of Connecticut's risk-based gun removal law: Does it prevent suicides? Law Contemp Probl. 2017;80(2):179-208. http://www.jstor.org/stable/45020002.

4.     Wintemute GJ, Pear VA, Schleimer JP, et al. Extreme risk protection orders intended to prevent mass shootings. Ann Intern Med. 2019;171(9):655-658. https://www.acpjournals.org/doi/abs/10.7326/M19-2162. doi: 10.7326/M19-2162.

5.     Swanson JW, McGinty EE, Fazel S, Mays VM. Mental illness and reduction of gun violence and suicide: Bringing epidemiologic research to policy. Ann Epidemiol. 2015;25(5):366-376. https://www.sciencedirect.com/science/article/pii/S1047279714001471. doi: 10.1016/j.annepidem.2014.03.004.

6.     Swanson J, Nestadt P, Barnhorst A, Frattaroli S.  Risk-Based Temporary Firearm Removal Orders: A New Legal Tool for Clinicians.  Harvard Review of Psychiatry.  2021; 29 (1): 6-9.  doi: 10.1097/HRP.0000000000000278.

7.     Frattaroli S, Sharfstein JM. Extreme risk protection Orders—A tool for clinicians to prevent gun violence. JAMA Health Forum. 2021;2(4):e210948. https://doi.org/10.1001/jamahealthforum.2021.0948. Accessed 4/18/2023. doi: 10.1001/jamahealthforum.2021.0948.