The Unhoused Encounter - Part II Significant Barriers To Accessing Quality Treatment Services

John Makohen The Unhoused Encounter Part II

September 29, 2025

John Makohen, Author & Co-Founder/COO, Educational Enhancement

Homelessness and substance use disorder often occur together, and unfortunately, many individuals facing both issues are unable to access the help they need. Substance abuse can develop as a response to the stressors linked to homelessness. Conversely, addiction can also lead to homelessness. Moreover, many homeless individuals suffer from addiction along with other co-occurring psychiatric disorders, which can make their living situations even more complicated.

If you or someone you care about is experiencing homelessness and addiction, it can be helpful to learn more about substance abuse, homelessness, and the treatment options available for those facing both. Visit https://americanaddictioncenters.org/rehab-guide/addiction-statistics-demographics/homeless for more information.

Do people experiencing homelessness often face significant barriers when trying to access quality substance use and mental health treatment?

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.

This is Part II of his series. Part I is linked below.

According to John Makohen:

The Unhoused Deserve Better: Why the System Is Failing People Who Need It Most

Let me tell you something most folks don't want to hear or believe. Being homeless and strung out on dope doesn't mean you've given up on life. Sometimes, it just means life and the system gave up on you first. I should know. I was there. Diagnosed by the Bloomberg Administration as chronically homeless. (Hmmm?) The Bloomberg Administration, a government body responsible for homeless services, labeled me as someone who was unable to maintain housing for an extended period, further perpetuating the cycle of homelessness and addiction.

At night, I was accustomed to the cold concrete beneath my body and a daily regimen of forty-plus bags of heroin with a gram of coke to stay alive. I had zero belief that I deserved anything better. I didn't end up on the streets because I was weak. I was running from trauma, drowning in pain, and sorrow. But often, instead of support, what I got was judgment. Disgust. Doors slammed in my face. Programs that only wanted me if I showed up sober, showered, and on time. What a joke.

The system says "treatment is available," but it never mentions the cost. An ID. A working phone. A stable address. Reliable transportation. And on top of all that—hope. Have you ever tried having hope when you haven't eaten in two days, and the only thing numbing the shame is your next shot of heroin? It's easy to preach recovery from behind a desk. It's a whole different story from Skid Row in Tompkins Square Park.

Stigma Is a Barrier

Most people don't even realize they're part of the problem. We talk about addiction like it's a moral failure. We call people "junkies" as if their pain is their fault. I internalized all of it. I believed I was garbage, that I was broken beyond repair. That I deserved the suffering. Every time a treatment center turned me away for being too dirty or too late, it confirmed what I already believed deep down. "You're not worth saving."

Even when I managed to reach out for help, the shame followed me in the door. Programs stared at my track marks before they looked me in the eyes. Miss two appointments, and suddenly I was "noncompliant." What I needed was not judgment, but empathy. Nobody asked if I was okay. Nobody cared that I couldn't get there because I didn't have a MetroCard, or I got jumped the night before, or I was just too depressed to drag myself out from under a pile of blankets in a stairwell.

The System Is Set Up to Fail Us. But it doesn't have to be this way. We can and must demand systemic change to ensure that everyone, regardless of their circumstances, has access to the support and resources they need.

Let's break it down. Here's what treatment programs expect from people like me:

• An address. Without one, good luck filling out intake forms or renewing Medicaid.

• A phone. If it's not stolen or dead, it's probably out of minutes.

• Insurance. You'd better be ready for endless paperwork and caseworker ping-pong.

• Transportation. Try navigating a subway map while withdrawing in the middle of February.

• Consistent behavior. When your nervous system is fried and your mind is in survival mode, you're lucky to show up at all.

And when do we arrive? We get programs that discharge us for being late. Counselors who treat us like statistics. Treatment plans that don't make space for trauma, housing instability, or the constant weight of being one wrong move away from death.

Mandated Treatment and The Abstinence-First Model

Let's discuss mandated treatment for a moment. You start dropping positive urine because, yeah, you're still unhoused, still traumatized, still living in chaos. Instead of asking what you need, the system tightens the screws. They send you to more groups, more one-on-one sessions, and special forced sessions stacked on top of each other. They call it "intensive," but it's just more of the same punishment dressed up as support. You don't get asked why your tox screens are lighting up like a Christmas tree. You just get labeled noncompliant. And the program makes more money while you suffer.

And if you're on Medicaid or public assistance? The pressure gets worse. Miss a group meeting, and you'll lose your benefits. Drop a positive, and you get dragged deeper into a system that thinks more hoops will fix your pain. I was stuck in daily groups just because my toxicology reports were always positive, and no one ever asked why. Not one person said, "What happened?" or "How can we help?" They just assumed I didn't 

care. But I did. I couldn't find a way to keep my demons at bay when I left the program and returned to the streets.

Abstinence-first might work for someone with a safe place to live and a solid support system. But when you're homeless? Whether you're sleeping on the street or in a shelter, it's guaranteed to be filled with dope and violence. 

The shelter system is not a place of healing. It's full of drugs, violence, and noise. It's like trying to recover in a war zone. You can't build a new life on quicksand. It's not the recovery first model. It's survival. And abstinence can't be your first step when your basic needs aren't even met. Abstinence-first programs are designed for individuals who are already on the path to stability, not for those still struggling to stay sober. The problem is that most programs follow the AA 12-step mentality as if it were a golden rule.

It's Not Just a System Problem. It's a Human Problem.

I wasn't an outlier. You'll hear the same story in shelters, stairwells, and street corners. "I tried to get help, but they made it impossible."

We tell people to reach out, then punish them for doing it imperfectly. We assume they don't want recovery, when the truth is they don't want to be humiliated one more time. Shame doesn't help people heal. It buries them.

That kind of shame? It sinks into your bones. After a while, you stop asking for help. You stop believing you're worthy of anything but this cycle. I lived in that space for years. And when I finally crawled out, it wasn't because some perfect program scooped me up. It was because something in me refused to die. I hung on long enough for a crack of light to get through.

What Needs to Change

If we're going to talk about fixing this, we have to stop building systems for people who already have their shit together. Recovery programs need to account for chaos. Period.

No wrong door. Whether someone walks into an ER, a soup kitchen, or gets picked up by outreach, they should get real help right away.

• Trauma-informed care. Stop punishing people for the very symptoms of what they've survived.

• Housing first. Nobody gets clean worrying about where they'll sleep tonight.

• Compassion over compliance. Late isn't laziness. Dirty isn't defiance. Human beings aren't checkboxes.

But let me tell you what did work: methadone maintenance treatment programs (MMTPs). The medications for opioid use disorder and harm reduction saved my damn life. It met me where I was. I didn't have to pretend I had it all together. My homeless crew and I visited clinics all over the city without being kicked out for missing a day or two. No threats. No punishments. I wasn't forced to see a counselor five times a week or sit through groups I wasn't ready for. My program was my program. It fit my messy, chaotic lifestyle. That person-centered approach gave me something I hadn't had in years—peace of mind. I finally had a little bit of stability, a medication that eased the withdrawal, and the time and space to start thinking about recovery on my terms. Not theirs. And that made all the difference.

Final Thought

People with substance use disorders who are unhoused aren't failures. They're survivors. And they're doing it in a system built to watch them fail.

That should make you furious. So if you've never slept on a bench but you care about the people who do, don't look away. Share this.

Donate if you can. Show up where it counts. Vote like someone's life depends on it.

And if you're out there, still in the thick of it, scraping by, still trying to believe you deserve better. I see you. Your story isn't over.

You're not a lost cause. You're just getting started.

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

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