{"edition":"california","organization":"Harm Reduction Services","organizationId":"org:harm-reduction-services","boundaryVersion":"US-CA-state-v1","updated":"2026-09-13","model":{"version":"ca-hrs-alpha-v2-conditional","costScope":"Full ordinary unrestricted recipient gift, analytically normalized to C=$100,000. All portfolio/support costs remain in the denominator. E/Y is total recipient expense per nominal annual SSP person, NOT SSP-only unit cost. No naloxone purchase price, restricted gift allocation or extra leverage is assumed. Third-party incremental resource costs remain unknown; this is a donor-dollar rather than societal-cost estimate.","geographicAttribution":"g_CA=0.98 central, 1 favorable and 0.9 adverse are explicit judgments about where direct survivor health is enjoyed. Sacramento and neighboring California service geography is observed; longitudinal residency/migration is not. No population-share or headquarters allocation.","formula":"Let E=1,695,969 USD/year and Y=5,000 nominal SSP people/year. N=(C/E)*Y*d*m*x is the expected unique opioid-risk people whose naloxone-response protection is additionally sustained, where d adjusts reported reach for stale/duplicate figures, m adjusts average scale for marginal funding replacement/capacity, and x is the fraction with relevant effective protection. Let h=lambda+mu. S_without(t)=exp(-h*t); S_with(t)=exp(-h*t+lambda*e*min(t,tau)). Q_all=N*u*integral_0^T [S_with(t)-S_without(t)]*exp(-r*t)dt. Q_CA=g_CA*Q_all; price_10_CA=10*C/Q_CA if positive. With a=h-lambda*e and A(k,z)=(1-exp(-k*z))/k, per-person q=u*[A(a+r,tau)-A(h+r,tau)+(exp(lambda*e*tau)-1)*(exp(-(h+r)*tau)-exp(-(h+r)*T))/(h+r)], for T>=tau. Protection changes only opioid fatal hazard for finite tau; afterward both arms again face the same recurrent overdose and other mortality hazards.","counterfactual":"Existing HRS portfolio, grants, state-supplied naloxone, other distributors, informal sharing and EMS continue without the donation. The central m=0.5 allows half proportional service expansion to disappear through replacement, reserves or capacity constraints. The e=0.1 reduction is incremental versus available alternative responses, not the biological reversal success rate.","attribution":"Count the expected unique-person cohort once, not a new lifetime for every kit or reported reversal. Use the full recipient cost so no extra program-allocation factor is applied. Give no additional QALY credit here to HIV/HCV prevention, case management, clinic care or treatment navigation because joint marginal pathways are unresolved; this is a partial-health portfolio estimate, not a demonstrated lower bound. Shared delivery and existing public naloxone are incorporated through marginal delivery/effect assumptions, without claiming that donor cash purchases the drug.","uncertainty":"This is a transparent subjective conditional best-estimate scenario, not an identified HRS treatment effect or statistical expected value. New primary accounts and self-reported scale anchor cost; d, m, x, risk and effect remain judgments. The wide favorable/adverse combinations are stress scenarios, not confidence limits or hard bounds. Zero benefit remains plausible. Other portfolio benefits and possible harms are unmodeled; the positive branch cannot certify net benefit.","nativeOutcomes":"Central: 294.817 nominal annual SSP service-person equivalents per $100,000 at total-recipient cost; 147.408 after d; 73.704 after m; 36.852 expected unique opioid-risk people with relevant additional protection after x. Their finite survival difference yields 0.330334 all-population QALYs and 0.323727 California QALYs. These are modeled additional people, not observed HRS outputs, rescued lives or kit counts.","inputs":[{"name":"C","value":100000,"unit":"USD ordinary gift","basis":"judgment","rationale":"Analytical normalization only; not an observed expansion request.","sourceIds":[]},{"name":"E","value":1695969,"unit":"USD recipient expenses/year","basis":"observed","rationale":"FY ending June 2025 original Form 990 Part IX total; all programs and support retained.","sourceIds":["hrs-990-2025"]},{"name":"Y","value":5000,"unit":"nominal SSP people/year","basis":"observed","rationale":"Schedule O reports approximately this scale; the wording and number are repeated in FY2023, so freshness and deduplication are not established. It is not verified additional or unique reach.","sourceIds":["hrs-o-2025","hrs-o-2023"]},{"name":"d","value":0.5,"unit":"current unique share of nominal reach","basis":"judgment","rationale":"Halve repeated self-reported annual scale because no fresh deduplicated series is available; scenario range 0.2–1, not an empirical interval.","sourceIds":["hrs-o-2025","hrs-o-2023"]},{"name":"m","value":0.5,"unit":"marginal delivery relative to proportional average scale","basis":"judgment","rationale":"Allow half otherwise proportional expansion to replace funding, replenish reserves or fail to add capacity. SSP reliance on donations makes positive delivery plausible; reserves/grants prevent assuming 100%. Range 0.1–0.8, with separate zero case.","sourceIds":["hrs-o-2025","hrs-funding","hrs-990-2025"]},{"name":"x","value":0.5,"unit":"share with relevant sustained opioid-overdose protection","basis":"judgment","rationale":"Not every SSP recipient uses opioids or gains a usable response network. Current SSP distributes Narcan and includes mobile outreach; reported training covers only 500 annually, so no assumption that all SSP recipients are newly trained. Range 0.2–0.8. This selects usable access among eligible opioid-risk recipients; e separately represents their conditional mortality reduction and does not repeat reach or funding discounts.","sourceIds":["hrs-ssp","hrs-o-2025"]},{"name":"lambda","value":0.02,"unit":"annual opioid-fatality hazard without gift","basis":"judgment","rationale":"External risk calibration, not HRS observation. Older California post-overdose ED cohort had 1,863 unintentional overdose deaths/100,000 person-years; Ontario cohort had 1.9% opioid-related mortality in one year. Both are selected recent-overdose cohorts, not general SSP users, and predate the current fentanyl environment. Range 0.005–0.04 is subjective.","sourceIds":["ca-post-overdose","ontario-post-overdose"]},{"name":"mu","value":0.03,"unit":"annual competing non-opioid mortality hazard","basis":"judgment","rationale":"Combined central all-cause hazard is 0.05/year; Ontario post-overdose all-cause mortality was 5.3%. Constant long-run hazard is a simplifying prior, not cohort survival follow-up. Range 0.02–0.05.","sourceIds":["ontario-post-overdose"]},{"name":"e","value":0.1,"unit":"incremental proportional opioid-fatal hazard reduction while protected","basis":"judgment","rationale":"Discounted transfer judgment: older ecological OEND study associated implementation with 27–46% lower community mortality, whereas recent bundled cluster trial estimated RR 0.91 with CI 0.76–1.09. Neither identifies individual HRS effect. Central 10%, stress 1–25%, plus zero, explicitly accounts for other responders and existing naloxone.","sourceIds":["walley","healing-rct"]},{"name":"tau","value":1,"unit":"years of additional protection","basis":"judgment","rationale":"One finite year, not permanent risk removal or one year for every repeated kit. Adverse 0.25 year.","sourceIds":[]},{"name":"T","value":10,"unit":"years of survival accounting","basis":"judgment","rationale":"Finite horizon; adverse 5, favorable 20. Continued high mortality in both arms prevents fresh full lifetimes after recurrent rescues.","sourceIds":[]},{"name":"u","value":0.7,"unit":"quality-adjusted life-year utility weight","basis":"judgment","rationale":"Health-state utility assumption, not a value assigned to the person. Stress 0.5–0.8; no HRS utility measurement.","sourceIds":[]},{"name":"r","value":0.03,"unit":"annual continuous QALY discount rate","basis":"judgment","rationale":"Explicit modeling convention in all scenarios.","sourceIds":[]},{"name":"g_CA","value":0.98,"unit":"California share of modeled health","basis":"judgment","rationale":"Mostly local direct beneficiaries, with allowance for migration; stress 0.9–1.","sourceIds":["hrs-ssp","hrs-o-2025"]},{"name":"incremental third-party cost","value":null,"unit":"USD","basis":"unknown","rationale":"Public drug stock, partner clinician time and other induced costs are not measured; societal cost-effectiveness would require them.","sourceIds":["ndp","hrs-m-2025"]}],"scenarios":[{"id":"central","label":"Central — subjective conditional estimate","costUSD":100000,"allPopulationQalys":0.3303339760120982,"editionQalys":0.3237272964918562,"assumptions":"{\"d\":0.5,\"m\":0.5,\"x\":0.5,\"l\":0.02,\"o\":0.03,\"e\":0.1,\"tau\":1,\"T\":10,\"u\":0.7,\"g\":0.98}; E=1695969,Y=5000,r=0.03,C=100000. Parameters d,m,x,lambda (l),mu (o),e,tau,T,u,g are judgments; this is not a confidence bound."},{"id":"favorable","label":"Favorable joint stress scenario","costUSD":100000,"allPopulationQalys":13.33219380511069,"editionQalys":13.33219380511069,"assumptions":"{\"d\":1,\"m\":0.8,\"x\":0.8,\"l\":0.04,\"o\":0.02,\"e\":0.25,\"tau\":1,\"T\":20,\"u\":0.8,\"g\":1}; E=1695969,Y=5000,r=0.03,C=100000. Parameters d,m,x,lambda (l),mu (o),e,tau,T,u,g are judgments; this is not a confidence bound."},{"id":"adverse","label":"Adverse joint stress scenario","costUSD":100000,"allPopulationQalys":0.000029107267018949653,"editionQalys":0.00002619654031705469,"assumptions":"{\"d\":0.2,\"m\":0.1,\"x\":0.2,\"l\":0.005,\"o\":0.05,\"e\":0.01,\"tau\":0.25,\"T\":5,\"u\":0.5,\"g\":0.9}; E=1695969,Y=5000,r=0.03,C=100000. Parameters d,m,x,lambda (l),mu (o),e,tau,T,u,g are judgments; this is not a confidence bound."},{"id":"zero","label":"No additional protection","costUSD":100000,"allPopulationQalys":0,"editionQalys":0,"assumptions":"m=0 or e=0: complete replacement, no capacity expansion or no improvement over existing responses. No finite positive cost-per-QALY."}],"sensitivity":["Central price is about $3.1 million per ten California QALYs; favorable about $75,000 and adverse about $38 billion. These simultaneous stress scenarios are not statistical confidence bounds.","Using only the reported 500 annual overdose-training participants as Y, without changing any other factor, divides benefit by ten and raises price to $30.89 million. This is a consequential alternative, not proof that existing SSP participants lack protective naloxone.","Replacing latest E with verified three-year expense mean $1,899,047.67 raises central price to $3,458,905.01. No cash-only expense series is inferred by subtracting donated contributions.","At fixed risk/survival assumptions, halving d, m, x or g halves QALYs and doubles price. d and m represent different mechanisms: reported unique/current scale versus financing additionality.","At central per-person q=0.00896377893 and g=0.98, $1 million per ten QALYs requires approximately 113.84 additionally protected people per $100,000; $100,000 requires 1,138.37. Central yields 36.85.","Zero is not excluded, and the favorable number is not an achievable offer. If the gift only sustains existing services that would otherwise continue, the incremental branch vanishes."],"missingInputs":["Fresh privacy-preserving annual unique SSP reach and overlap with training, opioid use and actual response networks.","Marginal staffing/outreach plan and unrestricted cash requirement; current grants, replacement behavior, restricted balances and capacity.","California client baseline fatality risk and differential timely response with versus without HRS, not reported reversal counts.","Duration of useful protection, recurrent mortality, utility and migration follow-up.","Joint non-overlapping HIV/HCV, treatment and clinic effects; incremental public/partner resource costs."]},"sources":[{"id":"hrs-home","title":"Harm Reduction Services home","publisher":"Harm Reduction Services","url":"https://hrssac.org/","published":null,"retrieved":"2026-09-13"},{"id":"hrs-ssp","title":"Syringe Service Program","publisher":"Harm Reduction Services","url":"https://hrssac.org/about-us/services-programs/","published":null,"retrieved":"2026-09-13"},{"id":"hrs-rw","title":"Ryan White Case Management","publisher":"Harm Reduction Services","url":"https://hrssac.org/ryan-white-medical-case-management/","published":null,"retrieved":"2026-09-13"},{"id":"hrs-era","title":"Education, Response and Access","publisher":"Harm Reduction Services","url":"https://hrssac.org/e-r-a-education-response-access/","published":null,"retrieved":"2026-09-13"},{"id":"hrs-clinic","title":"Joan Viteri Memorial Clinic","publisher":"Harm Reduction Services","url":"https://hrssac.org/joan-viteri-memorial-clinic-jvmc/","published":null,"retrieved":"2026-09-13"},{"id":"hrs-donate","title":"Donations","publisher":"Harm Reduction Services","url":"https://hrssac.org/donations-2/","published":null,"retrieved":"2026-09-13"},{"id":"hrs-funding","title":"Funding Sources","publisher":"Harm Reduction Services","url":"https://hrssac.org/funding-sources/","published":null,"retrieved":"2026-09-13"},{"id":"cares25","title":"2025 Grantees: Summary of Accomplishments","publisher":"The CARES Foundation","url":"https://www.thecaresfoundation.org/2025-grantees-summary-of-accomplishments/","published":"2026-04-30","retrieved":"2026-09-13"},{"id":"cares24","title":"2024 Grantees: Summary of Accomplishments","publisher":"The CARES Foundation","url":"https://www.thecaresfoundation.org/2024-grantees-summary-of-accomplishments/","published":"2025-04-29","retrieved":"2026-09-13"},{"id":"hrs-irs-extract","title":"Harm Reduction Services Inc IRS expense extracts","publisher":"ProPublica Nonprofit Explorer / IRS","url":"https://projects.propublica.org/nonprofits/organizations/680300656","published":null,"retrieved":"2026-09-13"},{"id":"ndp","title":"Naloxone Distribution Project FAQ","publisher":"California Department of Health Care Services","url":"https://www.dhcs.ca.gov/individuals/naloxone-distribution-project/ndp-frequently-asked-questions/","published":null,"retrieved":"2026-09-13"},{"id":"cdc-ssp","title":"Strengthening Syringe Services Programs","publisher":"CDC","url":"https://www.cdc.gov/hepatitis-syringe-services/php/about/index.html","published":"2024-03-20","retrieved":"2026-09-13"},{"id":"walley","title":"Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts","publisher":"Walley et al. / BMJ","url":"https://www.bmj.com/content/346/bmj.f174","published":"2013-01-31","retrieved":"2026-09-13"},{"id":"hrs-990-2023","title":"Form 990, fiscal year July 2022–June 2023","publisher":"Harm Reduction Services / IRS","url":"https://projects.propublica.org/nonprofits/full_text/202420889349301237/IRS990","published":null,"retrieved":"2026-09-13"},{"id":"hrs-990-2024","title":"Form 990, fiscal year July 2023–June 2024","publisher":"Harm Reduction Services / IRS","url":"https://projects.propublica.org/nonprofits/full_text/202531619349300013/IRS990","published":null,"retrieved":"2026-09-13"},{"id":"hrs-990-2025","title":"Form 990, fiscal year July 2024–June 2025","publisher":"Harm Reduction Services / IRS","url":"https://projects.propublica.org/nonprofits/full_text/202611289349303266/IRS990","published":null,"retrieved":"2026-09-13"},{"id":"hrs-o-2025","title":"FY2025 Form 990 Schedule O program descriptions","publisher":"Harm Reduction Services / IRS","url":"https://projects.propublica.org/nonprofits/full_text/202611289349303266/IRS990ScheduleO","published":null,"retrieved":"2026-09-13"},{"id":"hrs-o-2023","title":"FY2023 Form 990 Schedule O program descriptions","publisher":"Harm Reduction Services / IRS","url":"https://projects.propublica.org/nonprofits/full_text/202420889349301237/IRS990ScheduleO","published":null,"retrieved":"2026-09-13"},{"id":"hrs-m-2025","title":"FY2025 Form 990 Schedule M noncash contributions","publisher":"Harm Reduction Services / IRS","url":"https://projects.propublica.org/nonprofits/full_text/202611289349303266/IRS990ScheduleM","published":null,"retrieved":"2026-09-13"},{"id":"ca-post-overdose","title":"Mortality Following Nonfatal Opioid and Sedative/Hypnotic Drug Overdose","publisher":"Goldman-Mellor et al. / American Journal of Preventive Medicine","url":"https://pubmed.ncbi.nlm.nih.gov/32389530/","published":null,"retrieved":"2026-09-13"},{"id":"ontario-post-overdose","title":"One-Year Mortality After Emergency Department Visit for Nonfatal Opioid Poisoning","publisher":"Annals of Emergency Medicine","url":"https://pubmed.ncbi.nlm.nih.gov/31561997/","published":null,"retrieved":"2026-09-13"},{"id":"healing-rct","title":"Community-Based Cluster-Randomized Trial to Reduce Opioid Overdose Deaths","publisher":"HEALing Communities Study Consortium / New England Journal of Medicine","url":"https://pubmed.ncbi.nlm.nih.gov/38884347/","published":null,"retrieved":"2026-09-13"}]}