A spatial framework for selecting sentinel sites for drug and alcohol related early warning for the United States

Abstract The United States urgently needs a robust drug-related early warning system to effectively identify vulnerable areas and prevent successive waves of overdose epidemics. This research presents a statistical framework designed to fill this critical gap and strengthen efforts to prevent overdose-related harm nationwide. The sentinel counties are selected based on a geographic framework utilizing a modified version of the Agency for Toxic Substances and Disease Registry's Social Vulnerability Index, the Wide-Ranging Online Data for Epidemiological Research Multiple Causes of Death database, the National Highway Traffic Safety Administration’s non-fatal opioid overdose tracker, and the Drug Enforcement Agency's High Intensity Drug Trafficking Areas counties. Our results revealed geographic disparities across US counties, highlighting areas at highest risk for drug- and alcohol-related overdoses. These counties are prioritized for sentinel site selection under Drug Abuse Warning Network. Counties along the Texas, California, and Arizona borders were identified as particularly high risk and should be prioritized for surveillance. High-risk areas may be key drivers of the overdose crisis in the United States. These counties are unevenly distributed nationwide. The selected sentinel counties target these priority areas, advancing a geographic strategy for early warning. Sentinel sites can monitor emerging drug trends, novel substances, and evolving slang terms.