Social Determinants of Health and Fentanyl Overdose Mortality Across US Counties: An XGBoost and SHAP Analysis Identifying Silent Risk Counties and Treatment Deserts
Background: Fentanyl overdose deaths are still increasing across the U.S. We do not fully understand which county-level social and structural conditions lead to higher overdose death rates. Social determinants of health, including disability, treatment access, and behavioral health issues, may help identify vulnerable counties before deaths become severe. No earlier study has used explainable machine learning with SHAP attribution on 2022 CDC WONDER data to study treatment access gaps and silent risk counties. Methods: We combined data from four government sources for 975 U.S. counties, including CDC WONDER (2022) overdose mortality data, CDC Social Vulnerability Index (SVI), CDC PLACES health behavior data, and Area Health Resources Files. An XGBoost model was used to predict overdose mortality risk using Standardized Mortality Ratio (SMR). Five-fold cross-validation was used to test model accuracy, and SHAP values were used to show which factors increase or decrease risk. Results: XGBoost outperformed all tested models (Spearman rho=0.67, R2=0.457, MAE=0.409, high-risk recall=71.1%). Top predictors were disability rate, hypertension, smoking, and lack of vehicle access. Treatment desert counties had 52.6% higher overdose mortality (SMR 1.786 vs 1.170; p<0.0001). K-means identified 143 silent risk counties. Overdose deaths were spatially clustered (Moran's I=0.505, p=0.001) with 75 hotspots and 136 coldspots. Suppressed counties were 58.2% of WONDER counties, mostly rural (72%) and treatment deserts (65%). Conclusions: County-level SDOH factors predict overdose deaths, especially disability, treatment access, and behavioral health burden. MOUD expansion should prioritize treatment desert counties, and silent risk counties need early intervention before mortality worsens.