People’s Harm Reduction Alliance

Whole-recipient 2024 gross reported expense $2,727,457; not audited expense or cash spending; external clinical resources and volunteer time omitted.

King/Pierce/Snohomish only; central naloxone .50, MOUD/HCV .90 and injection/wound .80 are assumed local shares.

## Inspectable finite model Central naloxone coverage is 98,382 doses ÷ 2 doses/kit ÷ 6 kits/annual network person × .5 relevant-network conversion × .5 local share = 2,049.625 synthetic local people. This is not a finding that PHRA served exactly that many unique high-risk people. Kit recipients may be rescuers rather than patients, and multiple rescuers can cover the same patient; the divisor and conversion jointly address this unresolved mapping. A person faces one prospective overdose opportunity annually with otherwise-fatal probability .1, baseline rescue .75 and an additional .03 rescue probability. The constructed baseline mortality hazard is .025 other causes + .1 × (1 − .75) = .05, avoiding addition of overdose to an already all-cause hazard. For one support year, survival is exp(−hazard×time), followed by common .05 mortality in both counterfactual arms. Integrating their difference over 10 years, utility .65 and 3% discount yields finite health. Repeated events do not restart lifetime benefits. The buprenorphine subcohort is embedded within the same opioid cohort: only the incremental joint-survival difference beyond rescue is added. Treatment exposure is represented as full-year person equivalents, an approximation to the timing of shorter courses, not observed one-year retention. All mortality and utility horizons are priors; no life is assigned perpetual perfect health. Infection benefits use full-coverage equivalents derived from syringe counts, low annual infection risks and finite 10-year morbidity only. Susceptible people whose infection is prevented and already-infected people whose HCV is cured are conceptually disjoint; no HIV/HCV mortality or downstream transmission is credited. Incremental buprenorphine quality and short wound-care gains are separate from survival but remain weakly supported local priors. Finally, a .5 whole-budget response discounts proportional activity for the ability of cash to expand or preserve publicly supported services. It is conceptually different from alternative rescue at an overdose and alternative treatment for a patient, but these uncertainties may be correlated; the full-response diagnostic makes that potential overlapping conservatism visible. It gives a central price of $102K. Halving the rescue increment gives $389K; a five-year survival horizon gives $347K. Raising whole expense 25% for unmatched cost/service years gives weighted $100K. No coefficients were changed after observing the first result.

expense

2727457 2024 USD (observed). Derived gross original-return expense; not audited or cash cost. [irs2024]

doses

98382 2025 supplies (observed). Self-reported distribution; not unique local patients. [activity]

syringes

1254550 2025 supplies (observed). Self-reported distribution; not unique local patients. [activity]

dosesPerKit

2 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

kitsPerPerson

6 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

riskNetwork

0.5 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

local

0.5 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

opportunities

1 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

otherwiseFatal

0.1 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

baselineRescue

0.75 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

rescueIncrement

0.03 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

otherHazard

0.025 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

postHazard

0.05 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

horizon

10 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

utility

0.65 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

discount

0.03 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

budgetResponse

0.5 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

moudStarts

60 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

moudYears

0.5 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

moudAdditional

0.35 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

moudAttribution

0.65 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

moudLocal

0.9 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

moudHazardReduction

0.0052 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

moudUtility

0.05 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

syringesPerPerson

730 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

injectionLocal

0.8 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

injectionAdditional

0.3 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

hivRisk

0.001 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

hivReduction

0.34 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

hcvSusceptible

0.4 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

hcvRisk

0.03 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

hcvReduction

0.15 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

infectionUtility

0.03 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

infectionYears

10 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

hcvStarts

20 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

hcvSvr

0.9 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

hcvAdditional

0.25 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

hcvAttribution

0.6 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

hcvLocal

0.9 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

woundEpisodes

100 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

woundAdditional

0.3 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

woundLocal

0.8 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

woundUtility

0.1 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

woundDays

14 model parameter; see formula (judgment). Explicit conditional model parameter, not a verified PHRA local causal observation.

adverse conditional scenario: Cost: $2.7M; Seattle health QALYs: -2.16; all-population health QALYs: unknown. Negative rescue and infection effects; no treatment or wound gains.

null conditional scenario: Cost: $2.7M; Seattle health QALYs: 0.00; all-population health QALYs: unknown. Zero budget response.

cautious conditional scenario: Cost: $2.7M; Seattle health QALYs: 0.36; all-population health QALYs: unknown. 12 kits/person, .30 network, .35 local, .01 rescue increment, .08 post-hazard, 5-year horizon, .25 response, 20 MOUD and 5 HCV starts.

central conditional scenario: Cost: $2.7M; Seattle health QALYs: 13.43; all-population health QALYs: unknown. Disclosed default judgments; central is not weighted mixture.

favorable conditional scenario: Cost: $2.7M; Seattle health QALYs: 281.84; all-population health QALYs: unknown. 3 kits/person, .70 network, .65 local, .08 rescue increment, .035 post-hazard, 15-year horizon, .80 response, 120 MOUD and 40 HCV starts.

Counterfactual: Alternative timely rescue, treatment and public supplies remain available. Baseline rescue .75 and increment .03 are judgments.

Attribution: MOUD additionality .35 and PHRA share .65, HCV additionality .25 and PHRA share .60, injection additionality .30, and budget response .50 are uncertain and may correlate.

Subjective signed worlds: adverse .05, null .20, cautious .20, central .45, favorable .10. No calibrated probability claim.

Sensitivity

• Signed weighted mixture: $80K per DALY. The favorable case contributes 82.43% of net signed QALYs.
• Excluding the favorable case and renormalizing the remaining weights gives $409K per DALY.

Unresolved inputs

• Annual unique at-risk network people and overlap among rescuers, recipients and overdose patients
• Residence-specific King/Pierce/Snohomish share, rather than service address
• Counterfactual timely alternative rescue and incremental probability of rescue
• Treatment starts, retention, cures and partner attribution
• Current expansion or preservation capacity per additional unrestricted dollar
• Same-year cash/in-kind consumption bridge; independent financial-statement audit not reported.