Doc-Side Medical Clinic

Dr. G. Horvath has had  low key Downtown East Side medical clinic for many years. A family physician with advanced training in physical injury and addiction medicine, he manages this 'walk in clinic' as well as maintaining a methadone/suboxone clinic.
As an addiction psychiatrist I met him when I was licensing to provide methadone treatment. One of the most respected clinicians in the field he commonly trains new physicians in the addiction medicine practicums.
Licensed now in methadone treatment and well credentialled in psychiatry and addiction medicine,  I was actually happy to continue to work  at Doc-Side clinic if only because Dr. Horvath is an excellent colleague who is glad to share his knowledge on complex cases.  He's a doctor's doctor, a consumate clinician, caring and extremely conscientious.
I've worked here five years now.
In addition to managing methadone patients a couple of afternoons a week I provide psychiatric consultation to addiction medicine patients one morning a week.  This is possible because if patients don't show for an appointment the clinic has a 'stand by' arrangement so I'm able to work and not lose income.
Private psychiatrists who make up over 75% of psychiatrists tend to be cautious about seeing patients with drug or alcohol problems because this group is notorious for missing appointments. When a patient misses the appointment the doctor doesn't get paid. Since we're all running businesses with overheads of roughly forty per cent, drug addicts and alcoholics, often the most in need of psychiatric services, fall between the cracks.  Further the DTES patients are no able to pay the 'missed appointment' fees that the better heeled carriage trade can.
The other 25% of doctors work  in salaried positions with all the benefits. The public mental health programs have physicians as 'consultants' but mostly the patients see counsellors.  The 'team' approach is ideal to care but patients complain commonly about a variety of factors, some of which might well have validity.
At Doc-Side medical there is an Administrative Assistant and two or three administration personnel maintaining records, ensuring clinic payment and managing medication timing and urine testing.  The clinic costs at a methadone clinic are substantially more than a regular clinic because of the urine testing, random urine testing and required provincially mandated rules for clinic maintenance.
In British Columbia there are three forms of methadone license.  A physician or psychiatrist may have a license to prescribe methadone for pain. Methadone is a potent long acting narcotic that has specific benefits and use in oncology and palliative care as well as other areas of medicine.  I have this license but while I prescribe narcotics occasionally for pain haven't had a major pain practice in which I'd be using that license for this purpose.  Other narcotics not requiring special license are usually sufficient for most doctors who don't 'specialize' in pain areas specifically.
The second methadone license is that for prescribing methadone in a Methadone Treatment Clinic.  All the doctors working in methadone maintenance programs must have this special license and must in addition to academic training, have a day at least of apprenticeship experience with a senior methadone doctor.  Dr. Horvath, as an acknowledged leader in the field of heroin addiction and methadone maintenance is such an individual
The third methadone license is a clinic license.  Dr. Horvath, having a license for methadone maintenance also has a license to run a methadone clinic.  Methadone maintenance programs in the province are run out of clinics.  I and a half dozen more doctors who have a methadone prescribing license rotate through Doc Side Medical Clinic.  The requirement for a methadone doctor to have a methadone clinic license includes extensive experience and standards of excellence in their history of medical practice.  Others, such as pharmacists may obtain a 'methadone clinic' license, I believe, but the process is rigorous.
Because addiction is often associated with a higher risk lifestyle, from a public health perspective there is increased concern for communicable diseases and trauma associated illness.  There is further a very high overlap between addiction and alcoholism and co morbid psychiatric disorders.
Since working in the clinic I've treated all manner of psychiatric disorder, from gross psychosis, schizophrenia, neurotics, psychopaths, sociopaths, personality disorder, Bipolar disorders, Traumatic Brain Injury, Paranoid Disorders, Disocciative Disorders, Anxiety disorders  and alot of PTSD.
I was a supervisor in the Vancouver General Hospital Psychiatric Emergency so the psychiatric conditions are well within the range of my subspecialist training and experience. What is difficult about the work is the overall lack of resources.
Two of my suicidal depressed patients went to the hospital last year only to be turned away. They hung themselves. I don't fault the ER because the threat of suicide is high with alcoholism and addiction.  I only wish that I was there and  grandiosely hope that I might have stopped my patients from premature death.  Working with addicts and alcoholics I've seen more death than when I worked with HIV patients.  Suicide is difficult to deal with an I know many psychiatrists who have avoided the high risk areas choosing more boutique practices where patients are less suicidal and have more resources available to reduce the risks.
What I find interesting though here is the burden of physical illness I encounter.  The other doctors I work with, like Dr. Tsung and Dr. Kljajic are excellent family physicians like Dr. Horvath.  They have excellent cutting edge diagnostic and therapeutic knowledge .  I was a country family physician and treated the physical illness of many patients in my psychiatric practices but it's been often years for me in terms of therapeutics. I daily look up the latest treatments and often have luxury of asking one of my esteemed colleagues their opinions.
 Diagnostically I believe I'm far better than I was as a young doctor, simply because of experience.  I did appreciate asking my colleague when I saw a classic case of erysipalis.  Thankfully he knew what it was and what the treatment was.  I just recognised the pathology  but couldn't remember the name and treatment.  I am blessed with having seen so many patients I know 'normal' and am very alert when I see 'abnormal'.   The forms of cellulitis here are very variable. Last month I diagnosed a new TB case. Hep C is prevalent. I have several HIV patients.  Among ourselves invite each other to listen to heart murmurs and observe unusual patholgy. It's a joy working with other clinicians.
Only last month Dr. Horvath diagnosed a pulmonary embolism we all auscultated.  Last year I sent a patient to cardiology with myocarditis because the heart sounds were abnormal. We've felt our share of abnormal livers so don't bother each other with those.
 Every patient entering the Methadone Program gets a complete physical and standard screening laboratory and hematology testing. So we pick up our fair share of anemia and hypothryroidism.  I diagnosed a cancer last month sending the patient for confirmatory xrays and onto the appropriate sub speciality clinic at the hospital. I appreciate asking the other doctors who work on the same days I do their opinions and they seem very happy to have my psychiatric input on some of their more unusual patients.  Psychopharmacology is second nature to me as is physical pharmacology to them.  We do see a lot of trauma and order a number of ultrasounds and xrays. Dr. Horvath's orthopedic training has been as helpful as my rodeo doctor experience in diagnosing dislocations. Addiction obscure symptons and often patients aren't that good historians because of mental illness. So it all helps.
Methadone clinics reduce crime and disease spread by stopping the theft and sex trade that so often goes with addiction. But it's especially good for it reduces and stops illicit needle use. Doc Side Medical Clinic is a major unsung public health resource in the Downtown East Side,
In addition to the medical and administrative staff with patient follow up and administrative close contact with pharmacies we maintain a close collegial relationship with the various housing assistance programs, the major local detox programs such as Harbour Light  and the long term facilities such as Union Gospel. We're also fortunate to have a very good relationship with Vancouver's outstanding "drug court".   We encourage attendance in peer support programs such as NA and AA and the new SMART group programs routinely.
Presently there is a counsellor associated with Doc side who is here half the week. He's highly informed about various resources and has been most helpfull getting patients a variety of services. He's assisted people on the methadone program finding housing, getting rape crisis assistance, advocacy and as well provides both Cognitive Behavioural Therapy and Mindfulness Meditation Therapy for patients.
All we're lacking from my perspective is an outreach community nurse.  When a patient misses their methadone for three days the dosage must be lowered to the starting dose because of fears over overdose.  The pharmacists keep a record with computers of 'reversal' of methadone dosage. If a person were to miss 2 dosages an out reach nurse could find out what the problem is and hopefully arrange for the person to get their methadone rather than being lost to follow up. It's the one major disruption in care that often results in the patients ongoing relapse.  Relapse is common with addiction but the key is ensuring that the person gets back into the program as soon as possible. Further we have patients with major medical and mental health issues who just fall below the radar. A community nurse could follow up with a home visit to see what the concern is.  It's sad to say but patients have been found dead in tenements after days. This could be preventable.  I think of my patient who had a heart valve issue and simply with the winter cold didn't have the energy to get out to the pharmacy.  With a community nurse we would have found out early rather than late.  Just like my schizophrenic patient who became psychotic and afraid to leave his room when he stopped his anti psychotic medications.  The drug dealers sell door to door and do deliveries so we're commonly 'competing' with 'saving souls' from the lowest forms of drug dealers. It would be nice to have the resources.
Increasingly addiction is being conceptualized as very like an infectious disease. It 'spreads' through neighbourhoods.  This is especially true with young people.  A drug dealer will show up at a school or workplace or construction site also and slowly 'push' to a widening circle of addicts. It starts as 'recreational' but the aim of the dealer is to find the vulnerable because addicts are major cash cows.
The good news is that Recovery is even more 'infectious'.  For most of my patients , I am the only person they really get to know who is 'clean and sober'. They get to know the staff and counsellor then the pharmacists and slowly a widening circle of people who are normal surround them.  It's further recognised that physicians have a great deal of importance in initiating behaviour change.  It's no surprise that the Big Book of Alcoholics Anonymous 50 years since it's inception continues to start with the Doctors Opinion. A day doesn't go by that my colleagues aren't promoting smoking cessation and working here I see every once and a while their gargantuan efforts pay off.
Drug dealers are death salesman and they pile lies upon lies. Commonly patients are grossly misinformed about addiction and alcoholism. The methadone clinic is commonly their first contact with the recovery movement.
Thanks to the leadership of Dr. Horvath , all the doctors who choose to work at Doc Side maintain a recovery focus.  We encourage people to change their life style and get better health care and move onto abstinence based programs such as Narcotics Anonymous. We encourage patients to get into 'safe' housing.  We discourage crime. It's a great atmosphere to work in.
Research has shown that patients who are in well run methadone programs will tend to progress out of the sickness and criminal life and back to work and health and better social relationships by 2 to 3 years in methadone treatment programs. By contrast patients who continue to use heroin IV on the streets may be dead in that time or have acquired more chronic lifestyle related diseases. We also detox mostly younger patients over months from shorter addictions to heroin and other narcotics. Increasingly Suboxone has helped in this regard.
By contrast there have been reasonable criticism of some methadone clinics where the doctors and pharmacists were running a 'drug pushing' factory.  The patients were seen as 'customers' and the pharmacists especially didn't seem to want to lose the high priced drug sales that are associated with methadone maintenance programs.
The College of Physician and Surgeons of BC and the College of Pharmacists of BC are both involved in tight regulation of the programs overseeing training and maintenance. Personally critical of some of the highly expensive and destructive aspects of political correctness in government bodies I've only seen the finest work done by the College in this field.  The Colleges even have 'sting' operations and work closely with the Vancouver Police and RCMP to manage the programs. Just this summer 46 pharmacists and pharmacies lost their licenses to dispense.  Every once  in a while too a doctor is reprimanded for mostly negligent work. Dr. Horvath is asked, for instance, to review the work of colleagues and other clinics to ensure their records and management are at the standard set by the Colleges for this program.  The Colleges much to their credit run a very tight ship.  The area of addiction is rife with potential for abuse and corruption so I've grown to admire those in the College that ensure these programs run with excellence.
So Doc Side Medical Clinic is this rather low key clinic doing a rather large amount of work in an area of greatest need. There are other methadone clinics nearby where friends work  too.  I know they're 'run' with the same concern and consideration that Dr. Horvath shows. We often run into each other in the regular continuing medical education events for addiction medicine we attend each year. Most of us are certified with the Canadian Society of Addiction Medicine which maintains the highest standards of care.
Methadone clinics, especially the well managed ones, are often under appreciated and not that well understood. There are no Doc Hollywood  working here, that's for sure.  I daily see the work and it's paying off with time. I see the benefit.   Because we cover for each other I see my colleagues work and talk with their patients.  I especially appreciate the work of Dr. Horvath and the other doctors he's attracted to working in one of the most difficult areas of medicine, in one of the most notoriously difficult areas of Canada.  Doc Side Medical Clinic serves the the Down Town East Side of Vancouver (DTES).