As the nominal beauty editor for the website xoJane, Cat Marnell earned a loyal following with her dispatches from the glamorous hell of New York nightclubs, drug addiction, and psychiatric instability — disguised as beauty advice. (Representative posts include “I’LL TRY ANYTHING ONCE: Kleenex Eating for Appetite Suppression!” and “I ‘Monster Mashed’ in the Mental Hospital. Plus, Halloween, Nails!”) In her absorbing new memoir, How to Murder Your Life, Marnell gives the full account of her Adderall-fueled ascent through the ranks of Condé Nast beauty departments, where she was rewarded for the “amphetamine work ethic” that helped her tackle tedious tasks —organizing her boss’s desk, sorting through heaps of barely distinguishable beauty products —with gusto; her struggles with bulimia, addiction, and self-loathing; her stints in rehab and her professional redemption at xoJane. We hear how she set her hair on fire at a work event, but was too drunk to notice; how she spent her 27th birthday crying at a Narcotics Anonymous meeting; how she stopped sleeping, and fled her own apartment after hallucinating that it was overrun by rats.
One of the most revealing details, though, involves neither burning follicles nor imaginary vermin infestations. The ease with which Marnell duped various unwitting doctors into writing her the same prescriptions is startling to read. Her Adderall habit began in high school, when her father, a psychiatrist — hoping for a positive effect on his daughter’s GPA, never mind her brain chemistry — started writing her prescriptions. In New York— where she continued to receive packets of pills from her dad in Maryland — Marnell also started seeing her own psychiatrists, who pulled out their Rx pads after cursory consultations.
“The less I slept, the more emotionally and psychologically disorganized I became,” she writes. “But no matter how muddled I was, my doctor-shopping game was always on point.” She scheduled consultations for plastic surgery procedures she didn’t want, and left with scripts for post-op Vicodin or Percocet. She told one Upper East Side psychiatrist — the “ancient” Dr. M — that her primary doctor had retired, and demanded 80 milligrams per day of Adderall and Ambien. The doctors she visited didn’t question her exclusive commitment to them. When it came time to fill her multiple prescriptions, Marnell didn’t even get her hands dirty: She would send two different interns to two different pharmacies, a Walgreens and a Duane Reade, near the Condé Nast office in Times Square.
Marnell developed this routine in the mid-2000s — a few years before the abuse of prescription painkillers became a full-blown public-health crisis. Her portrayal of doctor-shopping offers a window into a behavior that helped fuel the epidemic.
“Doctor shopping is absolutely one of the biggest contributors to the opioid epidemic— definitely ten years ago, and even now,” says Anita Gupta, an anesthesiologist and adviser to the FDA. The prevalence of doctor shopping is difficult to measure —with its perpetrators and beneficiaries doing their best to avoid detection — but researchers believe it was a major factor in the painkiller abuse we see today.
When researchers in California analyzed the 17-million-plus prescriptions entered into a state database in the year 2007, they found that about 8.4 percent involved more than one provider or more than one pharmacy. The most common classes of drugs obtained through doctor shopping were opioids (like OxyContin and Percocet), followed by benzodiazepines (like Valium and Xanax), stimulants, and diet pills. In a 2012 survey at a southeastern university in the U.S., about 4 percent of students admitted that they had at least attempted to doctor shop. “While doctor shopping is a relatively rare behavior — only a fraction of one percent of controlled-substance patients engage in this behavior in most states — it still exists,” says Peter Kreiner, a scientist at the Institute for Behavioral Health at Brandeis University. “A fraction of one percent still represents hundreds, or in some states thousands, of people who are at risk for overdose and any number of health problems.”
Since the mid-2000s, when Marnell was at large, 49 states have created “Prescription Drug Monitoring Programs” — electronic databases of patients’ drug histories, which physicians are supposed to check before writing new prescriptions. (Opponents of the program in Missouri, the only state without some version of it, argue that a searchable compendium of sensitive medical information could pose a risk to patients’ privacy.) These efforts appear to be making a dent: In 2013, for instance, the year New York State put its program in place, the number of people filling prescriptions with five or more different doctors fell by 75 percent.
Brea Perry, a sociologist at Indiana University who has studied opioid abuse, categorizes doctors who write multiple prescriptions into four different groups. “Deficient prescribers” are “unaware of which prescription drugs are controlled substances,” and don’t know how to recognize symptoms of addiction in their patients. “Duped prescribers” — like Marnell’s geriatric “Dr. M” — are “gullible or careless or easy to manipulate.” These two groups, she says, are difficult to prosecute: “It’s hard to prove any kind of bad intent,” and they’re not entirely to blame, as “some of this comes from a lack of training.” The two other types of prescribers are less sympathetic. “Deliberate prescribers” sell drugs for profit, sometimes out of ersatz pain clinics or “pill mills,” and “drug-dependent prescribers,” who are addicted to controlled substances themselves, empathize too much with their dependent patients. She estimates that the majority of doctor shopping is clustered around about 10 percent of prescribers. “Most doctors are responsible,” she says. “They don’t have bad intentions. They’re really busy or they don’t have the training.”
Compared to the mid-2000s, doctor shopping “definitely isn’t as frequent,” says Gupta, “but it still could happen.” Not all doctors, for one thing, use the system the way it’s intended. “The ability of people like Cat Marnell to engage in doctor shopping depends a lot on prescribers’ checking or not checking their state prescription-drug monitoring program about a patient’s or prospective patient’s prescription history, before prescribing to them,” says Kreiner.
Even if providers do comply with the PDMP regulations, a determined addict can still find loopholes. If a patient went from doctor to doctor on the same day, for instance, they could game the system: “There’s a lag time,” Gupta explains. “By the time the system picks up the prescription, it could be a day, a week, a month.”
And there are, of course, other ways to get around the law. One friend of mine has been using her dog’s Xanax prescription for years. “No appointment required and the prescription can be filled at a grocery or CVS for $15,” she says. Another, hoping that Adderall could help her out of a post-college slump but lacking an ADHD diagnosis, told me how she looked up the symptoms of ADHD and the number of a local psychiatrist. “I remember saying that I felt like there was a coiled snake in my brain that darted up and ate whatever thoughts I was having as soon as I tried to concentrate — he liked that,” she said. “I laughed at all his jokes and walked out with a prescription.”