Impact of 30-day prescribed opioid dose trajectory on fatal overdose risk: A population-based, statewide cohort study.

BACKGROUND: Both increases and decreases in patients' prescribed daily opioid dose have been linked to increased overdose risk, but associations between 30-day dose trajectories and subsequent overdose risk have not been systematically examined. OBJECTIVE: To examine the associations between 30-day prescribed opioid dose trajectories and fatal opioid overdose risk during the subsequent 15 days. DESIGN: Statewide cohort study using linked prescription drug monitoring program and death certificate data. We constructed a multivariable Cox proportional hazards model that accounted for time-varying prescription-, prescriber-, and pharmacy-level factors. PARTICIPANTS: All patients prescribed an opioid analgesic in California from March to December, 2013 (5,326,392 patients). MAIN MEASURES: Dependent variable: fatal drug overdose involving opioids. Primary independent variable: a 16-level variable denoting all possible opioid dose trajectories using the following categories for current and 30-day previously prescribed daily dose: 0-29, 30-59, 60-89, or ≥90 milligram morphine equivalents (MME). KEY RESULTS: Relative to patients prescribed a stable daily dose of 0-29 MME, large (≥2 categories) dose increases and having a previous or current dose ≥60 MME per day were associated with significantly greater 15-day overdose risk. Patients whose dose decreased from ≥90 to 0-29 MME per day had significantly greater overdose risk compared to both patients prescribed a stable daily dose of ≥90 MME (aHR 3.56, 95%CI 2.24-5.67) and to patients prescribed a stable daily dose of 0-29 MME (aHR 7.87, 95%CI 5.49-11.28). Patients prescribed benzodiazepines also had significantly greater overdose risk; being prescribed Z-drugs, carisoprodol, or psychostimulants was not associated with overdose risk. CONCLUSIONS: Large (≥2 categories) 30-day dose increases and decreases were both associated with increased risk of fatal opioid overdose, particularly for patients taking ≥90 MME whose opioids were abruptly stopped. Results align with 2022 CDC guidelines that urge caution when reducing opioid doses for patients taking long-term opioid for chronic pain.

Handgun Ownership and Suicide in California.

BACKGROUND: Research has consistently identified firearm availability as a risk factor for suicide. However, existing studies are relatively small in scale, estimates vary widely, and no study appears to have tracked risks from commencement of firearm ownership. METHODS: We identified handgun acquisitions and deaths in a cohort of 26.3 million male and female residents of California, 21 years old or older, who had not previously acquired handguns. Cohort members were followed for up to 12 years 2 months (from October 18, 2004, to December 31, 2016). We used survival analysis to estimate the relationship between handgun ownership and both all-cause mortality and suicide (by firearm and by other methods) among men and women. The analysis allowed the baseline hazard to vary according to neighborhood and was adjusted for age, race and ethnic group, and ownership of long guns (i.e., rifles or shotguns). RESULTS: A total of 676,425 cohort members acquired one or more handguns, and 1,457,981 died; 17,894 died by suicide, of which 6691 were suicides by firearm. Rates of suicide by any method were higher among handgun owners, with an adjusted hazard ratio of 3.34 for all male owners as compared with male nonowners (95% confidence interval [CI], 3.13 to 3.56) and 7.16 for female owners as compared with female nonowners (95% CI, 6.22 to 8.24). These rates were driven by much higher rates of suicide by firearm among both male and female handgun owners, with a hazard ratio of 7.82 for men (95% CI, 7.26 to 8.43) and 35.15 for women (95% CI, 29.56 to 41.79). Handgun owners did not have higher rates of suicide by other methods or higher all-cause mortality. The risk of suicide by firearm among handgun owners peaked immediately after the first acquisition, but 52% of all suicides by firearm among handgun owners occurred more than 1 year after acquisition. CONCLUSIONS: Handgun ownership is associated with a greatly elevated and enduring risk of suicide by firearm. (Funded by the Fund for a Safer Future and others.).

Community-Level Risk Factors for Firearm Assault and Homicide: The Role of Local Firearm Dealers and Alcohol Outlets.

BACKGROUND: Identifying community characteristics associated with firearm assault could facilitate prevention. We investigated the effect of community firearm dealer and alcohol outlet densities on individual risk of firearm assault injury. METHODS: In this density-sampled case-control study of Californians, January 2005-September 2015, cases comprised all residents with a fatal or nonfatal firearm assault injury. For each month, we sampled controls from the state population in a 4:1 ratio with cases. Exposures were monthly densities of county-level pawn and nonpawn firearm dealers and ZIP code-level off-premises alcohol outlets and bars and pubs ("bars/pubs"). We used case-control-weighted G-computation to estimate risk differences (RD) statewide and among younger Black men, comparing observed exposure densities to hypothetical interventions setting these densities to low. We estimated additive interactions between firearm and alcohol retailer density. Secondary analyses examined interventions targeted to high exposure density or outcome burden areas. RESULTS: There were 67,850 cases and 268,122 controls. Observed (vs. low) densities of pawn firearm dealers and off-premises alcohol outlets were individually associated with elevated monthly risk of firearm assault per 100,000 people (RD pawn dealers : 0.06, 95% CI: 0.05, 0.08; RD off-premises outlets : 0.01, 95% CI: 0.01, 0.03), but nonpawn firearm dealer and bar/pub density were not; models targeting only areas with the highest outcome burden were similar. Among younger Black men, estimates were larger. There was no interaction between firearm and alcohol retailer density. CONCLUSIONS: Our results are consistent with the hypothesis that limiting pawn firearm dealers and off-premises alcohol outlet densities can reduce interpersonal firearm violence.

Anticipatory concerns about violence within social networks: Prevalence and implications for prevention.

Most research on exposure to violence focuses on direct victimization, offending, or witnessed violence, yet many people also experience concerns about potential violence in their environments and social networks. Using a state-representative survey of California adults (n = 2870) administered in July 2020, we estimate the prevalence of anticipatory concerns about violence within respondents' social networks and describe characteristics of the persons at perceived risk of violence, reasons for respondents' concerns, and actions undertaken by respondents to reduce that risk. Approximately 1 in 5 respondents knew at least one person, usually a friend or extended family member, whom they perceived to be at risk of other- or self-directed violence. Among respondents living with the person at perceived risk, about one-quarter reported household firearm ownership. Alcohol and substance misuse and a history of violence were among respondents' top reasons for concern; serious mental illness and firearm access also contributed to concerns. About one-quarter of respondents with such concerns said harm was likely or very likely to occur in the next year. Most respondents reported having taken action to reduce the risk of violence, including providing resources and asking family or friends to help; few acted to reduce access to lethal means. The most common reasons for inaction were the perception that a dangerous situation was unlikely and that it was a personal matter. Our findings can help inform a broader understanding of exposure to violence and interventions that leverage the knowledge of those close to persons at risk to prevent violence.

Trends and Sources of Crime Guns in California: 2010-2021.

Firearm-related interpersonal violence is a leading cause of death and injury in cities across the United States, and understanding the movement of firearms from on-the-books sales to criminal end-user is critical to the formulation of gun violence prevention policy. In this study, we assemble a unique dataset that combines records for over 380,000 crime guns recovered by law enforcement in California (2010-2021), and more than 126,000 guns reported stolen, linked to in-state legal handgun transactions (1996-2021), to describe local and statewide crime gun trends and investigate several potentially important sources of guns to criminals, including privately manufactured firearms (PMFs), theft, and "dirty" dealers. We document a dramatic increase over the decade in firearms recovered shortly after purchase (7% were recovered within a year in 2010, up to 33% in 2021). This corresponds with a substantial rise in handgun purchasing over the decade, suggesting some fraction of newly and legally acquired firearms are likely diverted from the legal market for criminal use. We document the rapid growth of PMFs over the past 2-3 years and find theft plays some, though possibly diminishing, role as a crime gun source. Finally, we find evidence that some retailers contribute disproportionately to the supply of crime guns, though there appear to be fewer problematic dealers now than there were a decade ago. Overall, our study points to temporal shifts in the dynamics of criminal firearms commerce as well as significant city variation in the channels by which criminals acquire crime guns.

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

BACKGROUND: Firearm 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. METHODS: This study was based on an analysis of interview data from six key informants involved in the passage of the GVRO legislation. RESULTS: Findings 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. CONCLUSIONS: This case study may inform efforts in other states to pass ERPO policies and other firearm safety laws.

Homicide Deaths Among Adult Cohabitants of Handgun Owners in California, 2004 to 2016 : A Cohort Study.

BACKGROUND: Although personal protection is a major motivation for purchasing firearms, existing studies suggest that people living in homes with firearms have higher risks for dying by homicide. Distribution of those risks among household members is poorly understood. OBJECTIVE: To estimate the association between living with a lawful handgun owner and risk for homicide victimization. DESIGN: This retrospective cohort study followed 17.6 million adult residents of California for up to 12 years 2 months (18 October 2004 through 31 December 2016). Cohort members did not own handguns, but some started residing with lawful handgun owners during follow-up. SETTING: California. PARTICIPANTS: 17 569 096 voter registrants aged 21 years or older. MEASUREMENTS: Homicide (overall, by firearm, and by other methods) and homicide occurring in the victim's home. RESULTS: Of 595 448 cohort members who commenced residing with handgun owners, two thirds were women. A total of 737 012 cohort members died; 2293 died by homicide. Overall rates of homicide were more than twice as high among cohabitants of handgun owners than among cohabitants of nonowners (adjusted hazard ratio, 2.33 [95% CI, 1.78 to 3.05]). These elevated rates were driven largely by higher rates of homicide by firearm (adjusted hazard ratio, 2.83 [CI, 2.05 to 3.91]). Among homicides occurring at home, cohabitants of owners had sevenfold higher rates of being fatally shot by a spouse or intimate partner (adjusted hazard ratio, 7.16 [CI, 4.04 to 12.69]); 84% of these victims were female. LIMITATIONS: Some cohort members classified as unexposed may have lived in homes with handguns. Residents of homes with and without handguns may have differed on unobserved traits associated with homicide risk. CONCLUSION: Living with a handgun owner is associated with substantially elevated risk for dying by homicide. Women are disproportionately affected. PRIMARY FUNDING SOURCE: The National Collaborative on Gun Violence Research, the Fund for a Safer Future, the Joyce Foundation, Stanford Law School, and the Stanford University School of Medicine.

Extreme Risk Protection Orders in Older Adults in Six U.S. States: A Descriptive Study.

OBJECTIVES: Extreme Risk Protection Orders (ERPOs) allow a court to restrict firearm access for individuals ("respondents") at imminent risk of harm to self/others. Little is known about ERPOs use for older adults, a population with higher rates of suicide and dementia. METHODS: We abstracted ERPO cases through June 30, 2020, from California, Colorado, Connecticut, Florida, Maryland, and Washington. We restricted our analysis to petitions for older (≥65 years) respondents, stratified by documented cognitive impairment. RESULTS: Among 6,699 ERPO petitions, 672 (10.0%) were for older adults; 13.7% (n = 92) of these noted cognitive impairment. Most were white (75.7%) men (90.2%). Cognitively impaired (vs. non-impaired) respondents were older (mean age 78.2 vs 72.7 years) and more likely to have documented irrational/erratic behavior (30.4% vs 15.7%), but less likely to have documented suicidality (33.7% vs 55.0%). At the time of the petition, 56.2% of older adult respondents had documented firearm access (median accessible firearms = 3, range 1-160). CONCLUSIONS: Approximately 14% of ERPO petitions for older adults involved cognitive impairment; one-third of these noted suicide risk. Studies examining ERPO implementation across states may inform usage and awareness. CLINICAL IMPLICATIONS: ERPOs may reduce firearm access among older adults with cognitive impairment, suicidality, or risk of violence.

Neighborhood Racial and Economic Segregation and Disparities in Violence During the COVID-19 Pandemic.

Objectives. To describe associations between neighborhood racial and economic segregation and violence during the COVID-19 pandemic. Methods. For 13 US cities, we obtained zip code-level data on 5 violence outcomes from March through July 2018 through 2020. Using negative binomial regressions and marginal contrasts, we estimated differences between quintiles of racial, economic, and racialized economic segregation using the Index of Concentration at the Extremes as a measure of neighborhood privilege (1) in 2020 and (2) relative to 2018 through 2019 (difference-in-differences). Results. In 2020, violence was higher in less-privileged neighborhoods than in the most privileged. For example, if all zip codes were in the least privileged versus most privileged quintile of racialized economic segregation, we estimated 146.2 additional aggravated assaults (95% confidence interval = 112.4, 205.8) per zip code on average across cities. Differences over time in less-privileged zip codes were greater than differences over time in the most privileged for firearm violence, aggravated assault, and homicide. Conclusions. Marginalized communities endure endemically high levels of violence. The events of 2020 exacerbated disparities in several forms of violence. Public Health Implications. To reduce violence and related disparities, immediate and long-term investments in low-income neighborhoods of color are warranted. (Am J Public Health. 2022;112(1):144-153. https://doi.org/10.2105/AJPH.2021.306540).

Privately manufactured firearms, newly purchased firearms, and the rise of urban gun violence.

Gun violence in many U.S. cities increased dramatically after the commencement of the COVID-19 pandemic. Surges in criminal access to untraceable privately manufactured firearms and new guns purchased from licensed dealers have been suggested as risk factors associated with the pandemic increase in gun violence. Official data on 4593 guns recovered in Oakland, California between 2017 and 2021 that were submitted to ATF for subsequent tracing are analyzed to determine whether the sources of crime guns changed and whether privately manufactured firearms and fast time-to-crime traced guns were more likely to be used in violent crime during this time period. Descriptive statistics are used to summarize the characteristics of firearms recovered during the study period and the results of ATF tracing. Logistic regression models are then used to assess systematic differences between firearms recovered during the pre-pandemic years as compared to firearms recovered during the pandemic years, and determine whether certain firearms are more likely to be recovered in violent crime. These analyses estimated large increases during the pandemic in the odds that recovered firearms were privately manufactured and recently purchased. Recovered privately manufactured firearms were also more likely to be associated with violent crimes. These findings support recent efforts to regulate privately manufactured firearms and continued efforts to reduce the illegal diversion of firearms from lawful commerce.

Extreme risk protection orders in response to threats of multiple victim/mass shooting in six U.S. states: A descriptive study.

Extreme risk protection orders (ERPOs), also known as red flag laws, are a potential tool to prevent firearm violence, including mass shootings, but little is currently known about the extent of their use in cases of mass shooting threats or about the threats themselves. We collected and abstracted information from ERPO cases from six states (California, Colorado, Connecticut, Florida, Maryland, and Washington). Ten percent (N = 662) of all ERPO cases (N = 6787) were in response to a threat of killing at least 3 people. Using these cases, we created a typology of multiple victim/mass shooting threats, the most common of which was the maximum casualty threat. The most common target for a multiple victim/mass shooting threat was a K-12 school, followed by businesses, then intimate partners and their children and families. Judges granted 93% of petitions that involved these threats at the temporary ERPO stage and, of those cases in which a final hearing was held, judges granted 84% of final ERPOs. While we cannot know how many of the 662 ERPO cases precipitated by a threat would have resulted in a multiple victim/mass shooting event had ERPO laws not been used to prohibit the purchase and possession of firearms, the study provides evidence at least that ERPOs are being used in six states in a substantial number of these kinds of cases that could have ended in tragedy.

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.

Gun violence restraining orders in California, 2016-2018: case details and respondent mortality.

BACKGROUND: Gun violence restraining orders (GVROs), implemented in California in 2016, temporarily prohibit individuals at high risk of violence from purchasing or possessing firearms and ammunition. We sought to describe the circumstances giving rise to GVROs issued 2016-2018, provide details about the GVRO process and quantify mortality outcomes for individuals subject to these orders ('respondents'). METHODS: For this cross-sectional description of GVRO respondents, 2016-2018, we abstracted case details from court files and used LexisNexis to link respondents to mortality data through August 2020. RESULTS: We abstracted information for 201 respondents with accessible court records. Respondents were mostly white (61.2%) and men (93.5%). Fifty-four per cent of cases involved potential harm to others alone, 15.3% involved potential harm to self alone and 25.2% involved both. Mass shooting threats occurred in 28.7% of cases. Ninety-six and one half per cent of petitioners were law enforcement officers and one-in-three cases resulted in arrest on order service. One-year orders after a hearing (following 21-day emergency/temporary orders) were issued in 53.5% of cases. Most (84.2%) respondents owned at least one firearm, and firearms were removed in 55.9% of cases. Of the 379 respondents matched by LexisNexis, 7 (1.8%) died after the GVRO was issued: one from a self-inflicted firearm injury that was itself the reason for the GVRO and the others from causes unrelated to violence. CONCLUSIONS: GVROs were used most often by law enforcement officers to prevent firearm assault/homicide and post-GVRO firearm fatalities among respondents were rare. Future studies should investigate additional respondent outcomes and potential sources of heterogeneity.

A comparative content analysis of newspaper coverage about extreme risk protection order policies in passing and non-passing US states.

BACKGROUND: Extreme risk protection order (ERPO) laws are a tool for firearm violence prevention (in effect in 19 states), often enacted in the wake of a public mass shooting when media coverage of gun violence tends to spike. We compared news media framing of ERPOs in states that passed and those that considered but did not pass such laws after the 2018 mass shooting in Parkland, Florida. METHODS: We conducted a content analysis of 244 newspaper articles about ERPOs, published in 2018, in three passing (FL, VT, RI) and three non-passing states (PA, OH, CO). Measures included language used, stakeholders mentioned, and scientific evidence cited. We use chi-square tests to compare the proportion of articles with each measure of interest in passing versus non-passing states. RESULTS: Compared to newspaper coverage of non-passing states, news articles about ERPOs in passing states more often used only official policy names for ERPOs (38% vs. 23%, p = .03), used less restrictive language such as "prevent" to describe the process of suspending firearm access (15% vs. 3%, p < .01), mentioned gun violence prevention advocacy groups (41% vs. 28%, p = .08), and referenced research on ERPOs (17% vs. 7%, p = .03). Articles about passing states also more often explicitly stated that a violent event was or could have been prevented by an ERPO (20% vs. 6%, p < .01). CONCLUSIONS: Media messaging that frames gun violence as preventable, emphasizes identifiable markers of risk, and draws on data in conjunction with community wisdom may support ERPO policy passage. As more states consider ERPO legislation, especially given endorsement by the Biden-Harris administration, deeper knowledge about successful media framing of these life-saving policies can help shape public understandings and support.

Talking about firearm injury prevention with patients: a survey of medical residents.

BACKGROUND: Firearm injury and death are significant public health problems in the U.S. and physicians are uniquely situated to help prevent them. However, there is little formal training in medical education on identifying risk for firearm injury and discussing safe firearm practices with patients. This study assesses prior education, barriers to counseling, and needs for improved training on firearm safety counseling in medical education to inform the development of future education on clinical strategies for firearm injury prevention. METHOD: A 2018 survey administered to 218 residents and fellows at a large, academic medical center asked about medical training on firearm injury prevention, frequency of asking patients about firearm access, and perceived barriers. RESULTS: The most common barriers cited were not knowing what to do with patients' answers about access to firearms (72.1%), not having enough time (66.2%), not feeling comfortable identifying patients at-risk for firearm injury (49.2%), and not knowing how to ask patients about firearm access (48.6%). Prior education on firearm injury prevention was more strongly associated with asking than was personal exposure to firearms: 51.5% of respondents who had prior medical education reported asking compared with who had not received such education (31.8%, p=0.004). More than 90% of respondents were interested in further education about interventions, what questions to ask, and legal mechanisms to separate dangerous people from their firearms. CONCLUSIONS: Education on assessing risk for firearm-related harm and, when indicated, counseling on safe firearm practices may increase the likelihood clinicians practice this behavior, though additional barriers exist.

Using Prescription Drug Monitoring Program Data to Assess Likelihood of Incident Long-Term Opioid Use: a Statewide Cohort Study.

BACKGROUND: Limiting the incidence of opioid-naïve patients who transition to long-term opioid use (i.e., continual use for > 90 days) is a key strategy for reducing opioid-related harms. OBJECTIVE: To identify variables constructed from data routinely collected by prescription drug monitoring programs that are associated with opioid-naïve patients' likelihood of transitioning to long-term use after an initial opioid prescription. DESIGN: Statewide cohort study using prescription drug monitoring program data PARTICIPANTS: All opioid-naïve patients in California (no opioid prescriptions within the prior 2 years) age ≥ 12 years prescribed an initial oral opioid analgesic from 2010 to 2017. METHODS AND MAIN MEASURES: Multiple logistic regression models using variables constructed from prescription drug monitoring program data through the day of each patient's initial opioid prescription, and, alternatively, data available up to 30 and 60 days after the initial prescription were constructed to identify probability of transition to long-term use. Model fit was determined by the area under the receiver operating characteristic curve (C-statistic). KEY RESULTS: Among 30,569,125 episodes of patients receiving new opioid prescriptions, 1,809,750 (5.9%) resulted in long-term use. Variables with the highest adjusted odds ratios included concurrent benzodiazepine use, ≥ 2 unique prescribers, and receipt of non-pill, non-liquid formulations. C-statistics for the day 0, day 30, and day 60 models were 0.81, 0.88, and 0.94, respectively. Models assessing opioid dose using the number of pills prescribed had greater discriminative capacity than those using milligram morphine equivalents. CONCLUSIONS: Data routinely collected by prescription drug monitoring programs can be used to identify patients who are likely to develop long-term use. Guidelines for new opioid prescriptions based on pill counts may be simpler and more clinically useful than guidelines based on days' supply or milligram morphine equivalents.

Firearm purchases without background checks in California.

Background checks are designed to prevent firearm acquisition by people prohibited from purchasing or possessing firearms. There is limited information about background checks, particularly on a state by state basis. We conducted a state-representative, probability-based, Internet survey of California adults in 2018 (n=2558; completion rate 49%) to describe where, when, and how firearms are acquired and to estimate the proportion of current firearm owners who purchased their most recent firearm without a background check. An estimated 17.2% (95% CI: 9.6-28.8) of firearm owners who purchased their most recent firearm within California in 1991 or later, following implementation of the state's comprehensive background check law, reported doing so without a background check. This percentage was 44.6% (95% CI: 27.1-63.5) among owners who purchased their most recent firearm before 1991 and 27.1% (95% CI: 13.1-47.7) among those who purchased their most recent firearm outside California. Firearm purchases without background checks occurred more often for firearms purchased from private sellers (72.3%; 95% CI: 35.5-92.5) than retailers (8.5%; 95% CI: 3.4-19.7). Overall, firearm purchases without background checks are considerably less common in California than in states without regulations on private sales. However, gaps in implementation and proper enforcement remain. Future research could investigate reasons for such lapses, as well as complementary state policy approaches that require background checks prior to point of purchase.

Impacts of prescription drug monitoring program policy changes and county opioid safety coalitions on prescribing and overdose outcomes in California, 2015-2018.

In 2015, California received funding to implement the Prescription Drug Overdose Prevention Initiative, a 4-year program to reduce deaths involving prescription opioids by 1) leveraging improvements to California's prescription drug monitoring program (PDMP) (i.e., mandatory PDMP registration for prescribers and pharmacists), and 2) supporting county opioid safety coalitions. We used statewide data from 2011 to 2018 to evaluate the Initiative's impact on opioid prescribing and overdose rates. Prescribing data were obtained from California's PDMP; fatal and non-fatal overdose data were obtained from the California Department of Public Health. Outcomes were monthly opioid prescribing rates and opioid overdose rates, modeled using generalized linear mixed models. Exposures were mandatory PDMP registration, presence of county coalitions, and Initiative support for county coalitions. Mandatory PDMP registration was associated with a 25% decrease (95%CI, 0.71-0.79) in opioid prescribing rates after 24 months. Having a county coalition was associated with a 2% decrease (95%CI, 0.96-0.99) in the opioid prescribing rate; receiving Initiative support was associated with an additional 2% decrease (95%CI, 0.97-0.98). Mandatory PDMP registration and county coalitions were associated with a 35% decrease (95%CI, 0.43-0.97) and a 21% decrease (95% CI, 0.70-0.90), respectively in prescription opioid overdose deaths. Both interventions were also associated with significantly fewer deaths involving any opioid but had no significant association with non-fatal overdose rates. Findings add to the knowledge available to guide policy to prevent high-risk prescribing and opioid overdoses. While further study is needed, coalitions and mandatory PDMP registration may be important components in such efforts.

Alcohol and drug offenses and suicide risk among men who purchased a handgun in California: A cohort study.

Firearm access is a risk factor for firearm suicide; substance use may confer additional risk. In this retrospective cohort study, we estimated the associations between prior alcohol and drug charges at the time of handgun purchase and subsequent suicide among men in California. The sample comprised all men who legally purchased a handgun in California in 2001 and who were age ≥ 21 at the time of acquisition (N = 101,377), identified in the California Department of Justice (CA DOJ) Dealer's Record of Sale database. Exposures included alcohol and drug criminal charges and convictions accrued January 1, 1990 until the first ('index') handgun acquisition in 2001, recorded in the CA DOJ Criminal History Information System. Outcomes included suicide and firearm suicide occurring after the index purchase and before January 1, 2016. A total of 1907 purchasers had alcohol charges, 1248 had drug charges, and 304 had both; 594 purchasers died by suicide (516 by firearm suicide). Compared with those with neither alcohol nor drug charges, those with alcohol charges had 2.20 times the hazard of suicide (95% confidence interval [CI], 1.39-3.46) and 2.22 times the hazard of firearm suicide (95% CI, 1.36-3.62). Risk was most elevated among those with more recent charges and those with 2 or more charges, and in the time period closest to the purchase. The associations for drug charges and the combination of alcohol and drug charges were not distinguishable from the null. Firearm owners with alcohol offenses may benefit from intervention to reduce firearm access and alcohol use.

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.