The Future of Substance Use Harm Reduction

SUD Harm Reduction: Use of Naloxone

August 12, 2025

John Makohen, Author & Co-Founder, Educational Enhancement CASAC 

Tom O'Connor, Publisher

Author John Makohen was a former street junkie and sex worker who endured 20 years of homelessness, heroin addiction, and internalized stigma. John hopes that sharing the dark and humorous truths about junk, selling queer sex, and homelessness will help others find some peace.

John is a seasoned substance use counselor who overcame 20 years as a street junkie. He wrote a book published on Amazon: A Heroin User's Guide To Harm Reduction: Staying Alive in the Age of Fentanyl, which skillfully combines his personal experiences with his professional knowledge to save lives. He is also a certified recovery coach and peer advocate, utilizing his personal and professional skills to empower and support individuals on their recovery journey.

He worked at Greenwich House, where he provided compassionate, kind, and evidence-based services to clients with opioid use disorder (OUD). John believes methadone saves lives and has the credentials and quality of life to prove it. He left Greenwich House to give 100% of his time to his online start-up, Educational Enhancement CASAC Online (https://educationalenhancement-casaconline.com/)

.  

According to John Makohen: 

Harm reduction has long been a contentious topic in public health. Critics dismiss it as enabling substance use, while advocates argue that it saves lives by meeting people where they are. The truth lies in the numbers: harm reduction strategies are effective. They lower overdose deaths, prevent the spread of infectious diseases, and connect people with resources they might not otherwise reach. 

However, as the drug landscape evolves, harm reduction must evolve as well. Emerging innovations like overdose prevention centers, fentanyl test strips, and digital tools are paving the way for a future where compassion and science take center stage. These practices not only represent a shift in how we address substance use but also hold the potential to transform treatment.

New York City Social Worker

When I was labeled with "chronic homelessness" and "depression" by some clipboard-wielding city social worker, I didn't even flinch. I was labeled and mistreated by NYC Visiting Nurses, DHS, and Mental Health Care over and over. Even though I'm successful, housed, and not shooting 40 bags of heroin with a gram of coke to chase it a day, my chest still gets tight, and my stomach turns to water when I sit in a waiting room for bloodwork because I know I'm going to get judged by the track marks that adorn my arms.

New York City Policemen

Cops didn't call me "chronically homeless." They called me a junkie. A thief. A whore. A waste. They didn't diagnose me. They cuffed me. Patted me down like I was hiding weapons instead of trauma. One officer once told me the shelter would be "too good" for someone like me. When your address is a park bench, and your pharmacy is the street, the world stops pretending you're human. I guess he was never brutally gang raped in the shelter on Ward's Island like I was.

Medical Staff

Medical professionals weren't any better. If you want to see what passive cruelty looks like, try walking into an ER with abscesses and no insurance, smelling like the sidewalk, and shaking from withdrawal. I did—plenty of times. And what I got wasn't treatment. It was punishment disguised as policy.

Let me tell you about the time I went to Beth Israel with an abscess the size of a grapefruit growing out of my lower back. They didn't give me a bed or a privacy curtain. No gown. Just a folding chair in the middle of the ER, pants removed with my crusty, pus-soaked undergarments dripping beside me. I was a spectacle. My abscess, the size of a grapefruit, was being lanced in front of patients and med students like I was a freak show exhibit. They spoke about me like I wasn't there. "IV drug user," they muttered.

Not "person." Not "patient." Just a "junkie". A warning. Something to stay away from.

This wasn't a one-off. This was normal.

The Medical System Is Still Playing God

You'd think medical professionals would be the first to get it, right? Wrong. Most of my trauma didn't come from the street. It came from waiting rooms.

The moment they found out I used drugs, my chart changed. I went from "man in pain" to "drug seeker." From "patient" to "problem." I didn't get follow-ups. I didn't get referrals. I had security guards standing too close and nurses who spoke around me as if I weren't conscious. It didn't matter that I was hurting. It mattered that I was marked.

Police Don't Do Healthcare

And don't get me started on how many times I got locked up instead of helped. Cops aren't therapists. They aren't medics. They aren't trained to handle addiction. But they show up to every overdose, every public use, every moment when someone's most vulnerable.

One winter night, I got arrested for sleeping in a stairwell during a snowstorm. I was freezing, sick, and starving. As the officer cuffed me, he looked down and said, "Should've thought about that before you started using." That's how stigma speaks. Cold. Dismissive. And wrong.

Substance Counselor Stigma

Stigma doesn't just exist on the streets—it appears in treatment rooms, staff meetings, and break rooms. I know this because I've experienced it. As a counselor who was on Medication-Assisted Treatment (MAT), 

I kept it to myself. Not because I was ashamed, but because I knew some of my coworkers wouldn't understand. I was tired of hearing "junkie," "crackhead," or that old line about MAT being "just swapping one drug for another." 

Every week in the case conference, I had to defend my choice to refer clients to MAT because evidence, outcomes, and client dignity weren't enough for some. Harm reduction taught me to meet people where they are. The real shame is that too many in this field still don't.

The Real Problem? Stigma

One of the most significant barriers to harm reduction is the societal and institutional stigma surrounding it. People who use drugs are often dehumanized and seen as problems to be solved rather than individuals in need of support.

This stigma also affects harm reduction strategies, as critics dismiss them as enablers of substance use. However, the data present a different picture: harm reduction saves lives, lowers healthcare costs, and connects individuals with the resources they need for recovery.

Stigma kills more than heroin ever could. Doctors, police, clinicians, and policies often treat drug users as disposable. Labels replace identities. Judgment overshadows care. How do we end this stigma? By embracing harm reduction.

Harm Reduction Works

Harm reduction is still framed as "controversial" in public health circles.

But the evidence is clear:

• Overdose prevention centers reduce deaths.

• 
  

  Fentanyl strips help people use it more safely.

• Naloxone reverses overdoses every day.

  

  Naloxone Spray

• Evidence proves that Medications, like Methadone or Buprenorphine, for substance use work.

Harm reduction doesn't promote drug use. It accepts that people use drugs and works to keep them alive long enough to heal.

Why Harm Reduction Isn't Radical. It's Survival

People often discuss harm reduction as if it were a controversial miracle or something brand-new. It's not. It's just honest. It says, "You're alive; let's keep you that way."

• It's giving out Narcan without judgment.

• It's safe consumption sites that don't ask why you're there.

• It's fentanyl test strips, so people don't die from one bad bag.

• It's vending machines with syringes instead of lectures.

However, the issue is that people often fail to show compassion to those they believe "deserve" their suffering. And that's what stigma does. It portrays people like me as disposable. It conveys to the world that our lives are less valuable—that our pain is our fault, that addiction is a moral failing rather than a coping mechanism.

Let me ask you this: 

• Why is an influencer with an alcohol use disorder, slamming down mimosas at brunch, considered quirky, cool, or elite? Yet someone nodding off on the train is viewed as a criminal, junkie, or waste?

• Why was I judged more harshly for track marks than an entrepreneur with a $1,000-a-day ketamine, Adderall, and psychedelic mushroom habit?

• 
  

Let's Talk Numbers, Not Morals

Because facts don't care about your views on drug use:

• Supervised consumption sites save lives. In New York City alone, hundreds of overdoses were reversed in the first year of operation.

• Naloxone saves lives. Community programs distributing Narcan kits have significantly lowered death rates in neighborhoods most affected by the opioid crisis.

• Fentanyl test strips save lives. A study published in the International Journal of Drug Policy showed that people who used them were more likely to use them safely or with others who could help in an emergency. 

• Medications for opioid and alcohol use disorder are effective because they reduce cravings, prevent relapse, lower the risk of overdose, and support long-term recovery, backed by decades of clinical research and real-world outcomes.

But people still resist this, not because it doesn't work, but because they dislike who it benefits.

We need policies that decriminalize survival strategies and invest in what works.

• Make fentanyl test strips legal in every state.

• Fund overdose prevention centers, just as we fund hospitals.

• Get Narcan into every public bathroom, every music venue, and bodega if necessary.

And more than that? We need to stop pretending that people who use drugs don't exist until they die.

--------------------------------------------------------------------------------------------------------------------

John Makohen also authored: A Heroin User's Guide to Harm Reduction: Staying Alive in the Age of Fentanyl and Xylazine and Resilience: Building Strength in Early Recovery. 

    If you enjoyed this article, 

Please forward this to a friend or colleague who might benefit from it!