Miracles is part of Hollywood Commuunity Hospital
at the Brotman Medical Center in Culver City, Ca.. It is
a nice facility. Large rooms, two beds to a room. Clean
and friendly environment.
I recently had the opportunity to speak with Dr. Jonathan
Reitman, the Medical Director of the Miracles
Detox Program. The meeting was arranged by Julia
Berkowitz, Business Development and Marketing
Manager at Miracles. The truth is these are the results
of the 2nd meeting between us. My computer and I
have a love-hate relationship. Each of us needing the
other, but when ever something goes wrong pointing
fingers, in my case literally in the computer’s figuratively,
at each other. One of us lost the file from the
first interview, I will stick with blaming the computer.
I enjoyed my time speaking with Dr. Reitman and Ms.
Berkowitz. Sitting with them the passion that they
show for their work is obvious, as is their compassion
for their patients.
Ted: Good morning. I am here with Dr. Jonathan Reitman
and Julia Berkowitz of Miracles Detox at Brotman
Medical Center. We are going to talk a little about
detoxing, where it is at, where it has been and what is
going on with it. Dr. Reitman, can you give me a little
bit of background on the program?
Dr. Reitman: Sure, so we are an inpatient detox unit. So,
that is what we are licensed to do, though we do offer
rehabilitation as well. We have always been proud of
the fact that we are a program that offers detox, that
is our primary mission, however we find it is very, very
important to introduce our patients to the recovery
process. Even when they are in the depths of their detox.
Many places don’t do that. Many places just have
people detox in a hospital bed, they have a nice TV,
they have a remote control, and that’s what they do all
day. That can be comfortable but it doesn’t introduce
them to any of the principals of recovery. We work
hard to do that and we do that through group therapy
and introduce them to the concept of twelve-steps. We
have counselors that work with our patients and try
to build a little bit of a foundation before our patients
leave here, so they have some hope of continuing the
rehabilitative process after they leave. I am always very
acutely aware of the limited role that we play if you
think about the trajectory of somebody who has addiction
or alcoholism. When they are in their disease, it
is a major decision to take a step to try and help themselves.
Sometimes people have the insight to do that
on their own; sometimes family pressures, pressures
from work or legal pressures help them along. Never
the less that is a critical moment to intervene, when
there is a window of opportunity. The step that we
are doing to break them physically from the addiction
is obviously very critical, because there can’t be any
progress without that, yet it is a very small piece of the
overall course of their treatment. After that is where the
real work happens. That is where, hopefully, people will
adopt a recovery program that will help them maintain
their sobriety and learn the coping skills that will allow
them to maintain their stress, their anxiety, their depression
and their pain without resorting back to their
drug of choice. We have a very limited role but a very
T: Absolutely. Where did Miracles start? How did that
R: Miracles is the successor to a program called Exodus.
Exodus is a program that has been around for decades
now. They were involved in both chemical dependency
treatment as well as psychiatric treatment. They ran
many outpatient psychiatric programs but they also
ran a detox program under the name of Exodus that
was housed at numerous different hospitals. Eventually,
Exodus made its way here in the late 1990’s and in 2007
Exodus, which ran this unit, which we now call Miracles,
moved on. They continue to exist, but they really only
have their psychiatric programs now. My associate Dr.
Honzel and I stepped in to become medical directors
of this program. We renamed it Miracles, since we were
no longer part of Exodus. We continue really a similar
mission, which is inpatient detox, introducing patients
to some sort of rehabilitative process and I’ll mention
it now, since we forgot it last time, running our outpatient
program. Therefore, we do have some sort of
resources where patients are able to continue the next
step of their treatment and come back for outpatient
treatment if they return home from here or go into a
T: Okay that’s great, really wonderful. You yourself have
been dealing with patients with chemical dependency
issues for a long time. How did you get started in this
R: Yes, it’s been going on for almost ten years now and
I honestly just fell into it. I was working in primary care
before I started working in this facility. I had some contacts
that were on the staff here, specifically Dr. David
Murphy, who was the founder and medical director
of Exodus and then some of the other physicians who
worked under him. I got a chance to join a practice
with Dr. Honzel, who is my associate, who was very
involved here and I was just, sort of, brought on board
and was mentored very well by those mentors. That
was a great gift because I never really had any intention
of working in this field. I think a shame; really, because
it highlights the fact that many physicians don’t really
get the exposure to treating chemical dependency in
the way that we do. I think many doctors in training
have this impression that all alcoholics and addicts are
the people that they ran into in there county hospital
rotations. They were treating drunken belligerent
people who were coming into the emergency room
and nobody wants to deal with that all, unfortunately.
They don’t understand that there is a completely
different realm where people are actually treated in
settings where we are used to handling these sorts of
situations and have things to offer them. That’s sort of
a shame. I had never had a positive exposure to that
before. It was really eye opening to see that there really
was quality treatment that we could provide. There
are ways of treating people who face those issues and
more importantly, the vast majority of people we treat
are not those belligerent drunks coming into emergency
rooms. They are people with lives to live that are not
that different from our own. They are people that work,
that have families and these are the people that we
treat by and large. That was a real eye-opening experience
and it continues to be.
T: As far as what, you’ve been seeing over the course of
the last decade. What types of changes have you been
seeing in the people coming in? I mean, is it primarily
alcohol or are you seeing other things?
R: There have definitely been dramatic changes over
the last ten years or so. Mostly in the since, that many
of the problems we’re having in dealing with prescription
drugs. Prescription drug abuse has exploded.
That’s really in a few main areas. I would say number
one would have to be prescription painkillers. Like oxycontin
and norco, that’s just proliferated dramatically. Right up
there with that is addiction to sedative pills like Xanax,
Valium and Klonopin things of that sort. Then
one would have definitely have to mention
the stimulates, like Adderall and Ritalin and things in those
classes. All of these and the numbers are there to show
it, the prescription of these has increased dramatically.
People are interested to know why and I think there
are a number of factors. One is that more and more doctors
have become comfortable prescribing
these things, whereas the prescribing of these
types of agents was more limited in the past. There is
also awareness on the part of patients and the public
abroad what these are. People find out through the internet
and their friends and they become savvy about
how to access these kinds of medications form their
doctors. The combination makes it very easy for people
to get prescriptions to these kinds of medications.
We’ve seen a dramatic increase in the rate of addiction
to these substances. Also, I think it is unfortunate, but
important to point out is the age of our patients and
especially the age at which patients become physically
addicted to potent agents like these gets younger
and younger all the time. Now, it’s commonplace for
us to see people that are eighteen to twenty years
old who are addicted to very high doses of things like
oxycodone and stimulants. That wasn’t the norm in
the past. The statistics were clear, up until about ten
years ago when people were ready to graduate from
high school the most common things they would have
encountered would be, of course, alcohol and secondly
marijuana. That’s not the case anymore. Now, the number
one drug high schoolers encounter is still
alcohol, but number two is prescription
painkillers, more so than
marijuana. It’s really creating a major problem on many
levels. We know that adolescents are very vulnerable
to the effects of using powerful psychoactive drugs like
these. To introduce agents that are this potent in that young
and susceptible an age group is having dramatic consequences.
T: Does part of that responsibility lie on the doctors?
R: Absolutely, I think that has to be pointed out. I think
there are a couple of issues. I think there is one class of doctors that is
simply irresponsible. We know that many doctors have
been prosecuted for running pill mills, where they will
give patients whatever they ask for. I think there is a
problem that is more subtle than that. Doctors that aren’t
purposely prescribing inappropriately, but perhaps
because of other forces. We have encouraged doctors
to treat pain more aggressively and to use opioids
more aggressively in a very concrete way. Doctors, in
state, are required to earn educational credits in
pain management that really promote the idea that we
should not be afraid to use opioid medications. That
the risk of causing addiction is quite low. Doctors have
been encouraged to do this, many doctors prescribe
these drugs trying to be compassionate, but not understanding
how serious the consequences could be.
I think that doctors are part of the problem. Not just
the bad ones that are out there clearly doing wrong,
but ones that are trying to do the right thing but are
maybe jumping into these medications sooner than
they should. It doesn’t help that sometimes patients
are questing for and actively seeking these out. I think
it is a complex problem, but you are absolutely right
the doctors are the gatekeepers and should be doing a
better job of monitoring these.
T: When somebody comes into Miracles how long is the
average stay? How long do you keep somebody?
R: I believe the average stay currently is five days. It can
be as short as two or three days in some very simple
and straightforward cases. For example, that would
be somebody coming from out of town. They have
already arranged to go into a rehab program, but the
rehab doesn’t do detox onsite. They say, “Well we really
want to make sure you are stable”, so we will provide
that service and get it wrapped up pretty quickly.
Versus the other extreme. As a registered facility, that
has medical nursing care and all the resources of a
community hospital we will treat some patients who
literally could not be treated in any other setting. For
instance, somebody who has a problem with addiction
but they also require dialysis, or they require intensive
physical therapy because they recently had surgery.
Perhaps they have psychiatric problems, and are not
stable enough to be in another setting. Maybe they
have other types of medical problems like asthma or
heart disease. We are really sort of the program of last
resort for some patients that can’t get the level of psychiatric
or medical monitoring they need somewhere
else. Just to give you an example of what sometimes
comes through our door, just within the last week,
we had somebody arrive who presented themselves
as a straightforward case of alcohol detox. That was
what they were requesting. Within twenty-four hours
it became clear they had a case of very serious alcohol
hepatitis. That required treatment in an intensive care
unit. They ultimately were transferred to UCLA for more
definitive care. It is not rare that we see cases that acute
or that severely ill come through our program.
T: I’m sure that happens a great deal. People under
addictions, well we don’t take care of our bodies. We
do let ourselves kinda fall apart that way. I guess, since
you people have psychiatric care, you find yourselves
dealing with many co-occurring disorders.
R: That’s a big part of our population. Somewhere between
thirty to almost fifty percent.
Julia Berkowitz: Maybe more so. We do have a psychiatric
facility across the street so we are able to treat either
condition depending on which one is more acute.
R: That’s right, but a great deal of our patients suffers
from some major depression, bipolar disorder, some
with schizophrenia and of course personality disorders.
Those are a big challenge. We are equipped to deal
with that in terms of the services and resources we
have, which is good.
T: That is good, that’s great.
R: I am a medical addictionologist but I work very
closely with our psychiatric staff members here to manage
those patients. In some cases, we do have patients
here who are seen by psychotherapists. Sometimes
we have patient who, when they have the clarity that
comes with just a little bit of time off their substances
realizes what they have been struggling with is some
unresolved grief. Never having the proper care for
trauma that they been through. Even though many
times people might say, “Right in the middle of detox
isn’t the proper time to start therapy,” sometimes the
need is so urgent that we will bring in a therapist. Start
to talk to these patients, start to establish a treatment
T: That is one of the things you have tried to do, promote
cooperation among the psychiatric community.
T: You mentioned that you get people started along
the steps to recovery. I know you have some programs
you run around here; I understand that meetings take
place here as well?
R: They do. We are very proud of the fact that we have
an alumni meeting that has been in existence for well
over twenty years. Many of the alumni that come to
that meeting got sober in the Miracles program, sorry
the Exodus program, twenty-five thirty years ago that
still come to our alumni meeting every week. We house
that meeting on site now. Many of our patients come
back for that; many of our patients come because it is
their favorite meeting that they attend. It tends to be
a very, very high-energy meeting. The reason why the
alumni come back is they really want to help they want
to give back. They are very motivated to do that and
this is the perfect opportunity to welcome the newcomers
when they most need to be welcomed. Many
of the patients we see are really brand new to this. They
really have no idea what to expect. I think the alumni
really appreciate that opportunity and, of course, just
keeping up with the people they went through treatment
with. In our meetings that we hold on this floor
for our patients, we will often have panels of alumni
or just people from the twelve-step programs from
around the community, to share their experiences and
provide some encouragement to the patients here.
That’s mostly what goes on with the onsite meetings.
Many of the meetings we hold are facilitated by counselors;
staff we have just to treat the patients that are
here and provide introduction on that basis.
T: Sure and do some process work?
R: That’s right. We should talk a little bit about what
happens when patients leave. In many cases a patient
will transition from here into a residential treatment
program or rehab from anywhere from thirty to ninety
days. Many instead of doing that will transition through
sober living and in those cases, we hope they will come
back to our outpatient program or perhaps they will be
in a different outpatient program or attending twelvestep
meetings. Some people will go home, but still
come back to our outpatient program. Some people
will just go their own way, which is not what we encourage,
but it happens. However, even in those cases
we are at least planting seeds. We are hoping they will
get the help that they need or find their way to it eventually.
Those are the usual trajectories for people that
land here and we are trying to help them find out what
the next step will be for them.
T: What do you see as the evolution of treatment?
Where do you see it going?
R: I think you brought up an important highlight that
we need to work collaboratively. Addiction is a very
complex disease and people need to be able to transition
between these different levels of care and not fall
through the cracks in the process. I think that’s been a
big problem in the past, that people will go for thirty
days in a program, then go home and whatever gains
they made will be lost if they don’t have the follow
through. We really need to partner with programs and
services in the community to make sure people don’t
fall through the cracks when they leave here, I think
that’s very important. Recovery is an ongoing process;
detox alone is not a definitive treatment. It’s an important
step but it’s just the beginning. Similarly, you could
say the same thing about a residential program, that’s
very important but it doesn’t get somebody through
the rest of their life. I see the evolution as needing to
partner well with ancillary providers, resources in the
community to make that this remains an ongoing and
hopefully lifelong process. The risk of relapse is very
significant when people return home, even after fairly
extended courses of treatment. What I really want
avoid is the revolving door phenomena. People coming
over and over into treatment again and not continuing
their treatment in any fashion. They leave hoping that
they have gained enough insight this time through
that they’ll be okay this time around; we just know that
doesn’t tend to work.
T: Yeah I know very many people…well a number of
people like that.
R: The other thing,
I think we hope that we will have better biological and
pharmaceutical treatments to help people. Obviously,
we’re still in the infancy of that. We have medications
that can help people to stay sober and help them resist
cravings, but they’re not terribly effective. They can be
helpful in some cases but I don’t consider those a comprehensive
treatment in and of themselves. I do talk to
patients about those, I will prescribe them when appropriate,
but I will always emphasize that they are just
one very small part of an overall treatment plan. I hope
to see further progress in that in the future. I hope we
have more powerful tools to help people with, but
right now, I am very aware that we are very limited.
T: I know that generally, we want people to practice abstinence,
but how do you feel about harm reduction?
R: I’m all for whatever helps people. To take what’s a
good example. Methadone maintenance programs
have been around for forty years. The notion strikes
fear in the heart of some people and others are very
much for it. I think you have to each case on a case-bycase
basis. I think few people find the idea appealing
that they would be on methadone for some extended
period of time, or the rest of their life, but there is no
doubt that some people on methadone have been
able to stabilize their lives. To be able to become
productive in their lives. To stop using heroin and stop
injecting drugs, to stop sharing needles and things of
that sort. Everything has its place. I don’t think there is
one solution that is appropriate for everybody. Harm
reduction strategies are important to study and important
to use in some cases where that may be thing
the only thing that is realistically going to work. Our
ideal goal is always abstinence no doubt about that.
That would be what I want for myself, or anyone that
was close to me. I am also a realist, we live in an imperfect
world and sometimes we have to take advantage
of harm reduction strategies, or we run the risk that
we’re really not helping somebody.
It is interesting to see, we work with many different
programs, and we work collaboratively with a range
of programs with very different philosophies. We have
some sober living or treatment programs that will
absolutely insist that when somebody arrives at the
program they will not be on any medications at all. We
will try our best to accommodate that, even though it
can be very difficult. We will have others that have a
completely different point of view. They’ll say as long
as they are medications being prescribed responsibly
we don’t have any problem with that. You’ll see a wide
range of points of view on this out there. That’s another
reminder that we have to be flexible and understand
that there are different points of view and different
things that will work for different people. We have to
open to that. That’s a big challenge.
T: I ask people this a lot; this is just a personal curiosity
thing. Has the ACA been having any kind of effect that
you have been seeing?
R: That’s a great question. Not yet, but we have had
legislation passed that there must be what’s called parity.
Meaning mental health services must be covered in
a proportional fashion to other access to medical care.
Chemical dependence falls within that, so the hope
would be that as more and more people get insurance
we guarantee that there will be chemical dependency
coverage, that it will open the doors for more people.
I’m hopeful that that will be the case but I’m uncertain
that it will be. Part of the problem is that insurance
companies get to define when people are able to
access services. Sometimes their criteria are somewhat
narrow and restrictive and not helpful. I think it is in an
evolution, very clearly. I’m trying to be optimistic that
we will see more people able to access high quality
care, but right now, nobody knows exactly how it will
turn out. Maybe things will change over time as it is implemented
and we see what types of coverage people
are able to access.
T: That seems to be a pretty much universal type of
attitude, kind of wait and see. It could be kind of scary.
R: I will say that one of our frustrations is that we run
into certain situations where insurance companies
simply will not cover treatment at this level of care, for
something they consider not medically necessary. That
can be things that often times to the layperson can
seem often times very necessary medically, like someone
who is actively injecting heroin or methamphetamines.
Under many insurance policies that would not
qualify for inpatient treatment. They would say, “You
simply need to go to your doctor and get prescribed
medications and do it at home.” That’s very shortsight
ed when you consider the home situation or lack of
even a home situation that many people are coming
T: Well, yeah. Apparently, we aren’t lobbying very well.
R: That is a problem, we need more advocacy.
T: Dr. Reitman is there anything you would like to add?
R: I just want to emphasize that we are very proud of
the program we have built here. There aren’t many
facilities left that do what we do. We hope to be able
to expand the types of services we provide, the types
of patients that we are able to treat. I am optimistic; I
hope that in the future we might be able to find ways
to allow for greater lengths of stay for our patients. I
think that would improve their outcomes a lot. I think
one of the trickiest things is that as the types of addictions
people have grow more and more complicated,
in terms of these potent substances they are becoming
addicted to we need more and more time to stabilize
those patients. We are so limited in terms of that, that
one of the things I would really like to see. For us to
have the time to really see people through the longer
periods of stabilization that would allow them to have
T: That’s very true, that goes back to maybe the advocacy.
R: That’s right.
T: I want to thank you for your time. I also have Julia
Berkowitz her, the Marketing Director for Miracles. Maybe
you would like to follow up by answering a couple
of questions? What kind of capacity do you have here
Julia: Our capacity on the floor is eighteen, but we are
able to overflow at twenty-five. As we said before we
have the ability to take care of a patient with medical
needs that is also doing an acute detox so we have
medical floor beds available for that. Then we have an
outpatient for both psych and an IOP for psyche, substance
abuse addiction. I think we are currently putting
together a night program.
R: That would be an evening outpatient program.
J: You know it can be a little difficult for people that are
still trying to maintain their jobs. That’s a “to come in
the future”, a little sneak peak.
T: Do you do the IOP here onsite?
J: We do, it’s downstairs.
T: You see, I didn’t even realize that.
J: It’s actually across the street in that building, temporarily
while we are renovating we have it in this
building. It’s convenient for our patients. We are doing
some expanding. We have some new programs we will
be unveiling maybe in the summer. Although we are
known as Brotman Medical Center, we will be having a
name change this summer.
R: I was wondering when we were going to do that.
Hollywood Community Hospital at Brotman Medical
Center is quite a mouthful.
T: Do you ever going over to the Sony parking lot and
leave flyers on the windows. It would probably be a
great place to drum up business. (The Sony studio is
right down the street).
J: We have a relationship with Sony, but it is hard to get
in the parking lot, their security is very tough.
You can listen to a recording of the interview on the
main page. It’s very informative and amusing as I
stutter and fumble for words. Ahh...good times....good
Interview by Ted Dunn