Laboratories of Harm Reduction and Treatment: Determinants of States’ Policy Adoptions to Address the Opioid Epidemic

Abstract Context: In the US federal system, states have adopted a wide array of opioid-related policies over the past 30 years to address the ongoing overdose crisis. The underlying factors driving this variation remain unclear. Understanding what influences states to adopt more comprehensive policies—and whether they prioritize harm reduction or opioid use disorder treatment—has important implications for public health strategy and policy making. Methods: This study develops state-level indexes using dozens of policy indicators to measure the comprehensiveness of opioid-related policies across two dimensions: harm reduction and treatment. Feature rank analysis and multilevel mixed-effects regression are employed to assess the influence of various political, epidemiological, and socioeconomic factors. Findings: The authors find that decreases in conservative citizen ideology, increases in the severity of the overdose crisis, and increases in states’ economic resources are the most consistent factors influencing adoptions of more comprehensive policies. These factors shaped both the overall robustness of state responses and the emphasis on specific policy dimensions. Conclusions: This study highlights key drivers behind the variation in state-level opioid policy comprehensiveness, offering a clearer picture of how political and contextual factors influence public health policy making. These insights can guide future research on state-level health policy adoption.