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JAMA Forum
April 15, 2021

Extreme Risk Protection Orders—A Tool for Clinicians to Prevent Gun Violence

Author Affiliations
  • 1Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
JAMA Health Forum. 2021;2(4):e210948. doi:10.1001/jamahealthforum.2021.0948

Recent, widely publicized mass shootings in Atlanta, Georgia, Boulder, Colorado, Orange, California, and elsewhere have resurfaced questions about what can be done to prevent these terrible events. Nineteen states—as politically diverse as Florida and California—have laws on the books to temporarily prohibit gun purchase and possession by people who are behaving dangerously and at risk of committing violence, including self-harm. However, early evidence indicates that few clinicians are aware of how to use this emerging legal tool to prevent violence.

Here are the basics. In each state that has authorized what are called extreme risk protection orders (ERPOs), the law sets out who can file a petition with a civil court about someone of concern. Eligible petitioners always include law enforcement officers; in most states, family members are eligible, and in Hawaii, Maryland, and Washington, DC, clinicians are on the list. The petitions specify the reasons for concern, such as threatening violence, illegally and recklessly brandishing a gun, or articulating a suicide plan. A judge then reviews the request and decides whether to issue an ERPO. In most cases, the petitions are granted, leading to temporary removal of firearms for up to 1 year. After the order has expired, the people on whom restrictions are levied are able to regain possession of their guns and buy new guns. The ImplementERPO website includes detailed information about state ERPO laws.

The ERPO laws are based on public health principles that focus on risk and offer a strategy to reduce the lethality of that risk.1-3 They are a tool for intervening early in the trajectory of violence, before behaviors occur that rise to the level of a crime or life-threatening self-injury. They are also a mechanism for providing help to individuals at risk for committing violence, rather than waiting for tragedies to occur. At the same time, these laws are designed to be fair to individuals and respect their Second Amendment rights.

So far, the ERPO process has been used thousands of times around the country. In one instance, for example, a woman filed an ERPO petition with her husband, who suffered from depression and was experiencing suicidal thoughts. They testified together, with the husband acknowledging the danger of having access to guns at that time in his life. In another instance, law enforcement filed for an ERPO after responding to a call from a university. One student had been making repeated, specific threats to shoot several classmates. His agitated state further amplified the threat, and several students approached a faculty member, who called the police. In a state where clinicians can petition, an ERPO was used prior to discharging a patient who had survived a suicide attempt involving a gun. The clinical team was more comfortable discharging the patient, knowing he would be returning to a home without guns.

There is ample reason to believe ERPOs are being used to address situations where the threat of violence is real and imminent. A review of ERPO use in California identified 21 cases in which an ERPO was used in response to a mass shooting threat.4 Using data from King County, Washington, a study found 95% of the temporary ERPOs granted were in response to either violent acts or brandishing a firearm. Nearly all (87%) of the ERPO petitions filed in King County resulted in a judge issuing a 1-year ERPO.5 A study of Connecticut’s risk-based gun removal law estimated that for every 10 to 20 firearm removal orders issued by the court, 1 suicide was prevented.6

The decision by Hawaii, Maryland, and Washington, DC, legislators to include physicians, psychologists, and certain other clinicians among those authorized to file ERPO petitions with civil courts makes good sense. Clinicians are positioned to witness patients behaving dangerously, trained to ask about suicide risk, and accessible to families when a loved one is in crisis. Many clinicians already provide lethal means counseling, which seeks to help families reduce the chance a loved one will die by suicide.7 In 2019, the Veterans Administration and the Department of Defense published clinical practice guidelines for clinicians caring for patients at risk of suicide that included recommendations for lethal means counseling.8 The ERPO laws complement lethal means counseling by providing a mechanism to remove guns when the risk is high and the likelihood of people voluntarily relinquishing their firearms is low.

Unfortunately, evidence suggests that most clinicians are not aware of ERPOs. A survey of hospital-based physicians in Maryland, where physicians are authorized ERPO petitioners, revealed that 72% were not at all familiar with ERPOs.9 After reading a brief description of the law, nearly all respondents indicated they would consider using an ERPO if a situation warranted urgent intervention.

To close these gaps, clinical professional organizations can learn about ERPO laws in their areas and train their members on how to appropriately use them; continuing medical education courses are already becoming available. In states where clinicians can file petitions directly, professional education can focus on best practices for recognizing risks and processes for filing ERPOs, as well as legal pathways to keep patients safe. In states where clinicians cannot file directly, clinicians can learn how to counsel family members about ERPOs or contact law enforcement officials and ask them to file an ERPO petition when there are clear and present risks to health. Clinicians and their professional societies can also consider joining advocacy efforts for the passage of sensible ERPO laws in the 31 states that do not have them. Recently, President Joseph Biden announced that the US Department of Justice will publish a model ERPO law for states and called on Congress to pass a federal version.

Of course, ERPOs will not prevent all mass shootings. Nonetheless, they are an important piece of the puzzle for reducing gun violence in the US. When clinicians participate in the ERPO process, it is another way for trained health professionals to save lives.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Frattaroli S et al. JAMA Health Forum.

Corresponding Author: Joshua Sharfstein, MD, Bloomberg School of Public Health, Johns Hopkins University, 615 N Wolfe Street, Baltimore, MD 21205 (joshua.sharfstein@jhu.edu).

Conflict of Interest Disclosures: Dr Frattaroli reported grants from the National Collaborative on Gun Violence Research and Bloomberg American Health Initiative and payment support from the Johns Hopkins Center for Gun Violence Prevention and Policy for a publication fee for an article on extreme risk protection orders, outside the submitted work. No other disclosures were reported.

Frattaroli  S, McGinty  EE, Barnhorst  A, Greenberg  S.  Gun violence restraining orders: alternative or adjunct to mental health-based restrictions on firearms?   Behav Sci Law. 2015;33(2-3):290-307. doi:10.1002/bsl.2173PubMedGoogle ScholarCrossref
Swanson  JW, Nestadt  PS, Barnhorst  AV, Frattaroli  S.  Risk-based temporary firearm removals: a new legal tool for clinicians.   Harv Rev Psychiatry. 2021;29(1):6-9. doi:10.1097/HRP.0000000000000278PubMedGoogle ScholarCrossref
Consortium for Risk-Based Firearm Policy. Extreme risk protection orders: new recommendations for policy and implementation. Published October 2020. Accessed April 14, 2021. http://www.efsgv.org/ERPO2020
Wintemute  GJ, Pear  VA, Schleimer  JP,  et al.  extreme risk protection orders intended to prevent mass shootings: a case series.   Ann Intern Med. 2019;171(9):655-658. doi:10.7326/M19-2162PubMedGoogle ScholarCrossref
Frattaroli  S, Omaki  E, Molocznik  A,  et al.  Extreme risk protection orders in King County, Washington: the epidemiology of dangerous behaviors and an intervention response.   Inj Epidemiol. 2020;7(1):44. doi:10.1186/s40621-020-00270-1PubMedGoogle ScholarCrossref
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Barnett  BS, Kudler  H, Swanson  J.  To prevent suicide among veterans, their physicians should discuss gun safety.   JAMA Health Forum. Published online November 23, 2020. doi:10.1001/jamahealthforum.2020.1407Google Scholar
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. doi:10.1001/jamanetworkopen.2019.18037PubMedGoogle Scholar
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