“The Hard Sell” is a living story of an opioid company presented in the Boston trial

Now, almost exactly three years after the trial began in US District Court in the Seaport District, Evan Hughes has written The Hard Sell: Crime and Punishment at an Opioid Startup. It’s a focused and insightful account of how a company that went public in the most successful IPO of 2013 soon became a poster child for corporate greed and harassment, a company so corrupt that prosecutors were using federal laws to ban it created to fight, the Mafia hunted down.

I was among the journalists covering the 10-week trial, and for many of us, the most jaw-dropping moment came when prosecutors played the jury a polished, throbbing rap video shot by two young members of Insys’ sales team for a national sales meeting was produced in 2015. Wearing sunglasses and hoodies, the salespeople danced alongside an executive dressed as a Subsys spray bottle and sang their own lyrics to an A$AP Rocky song to get colleagues to get more doctors to buy the painkiller to prescribe. Subsys was up to 100 times more potent than morphine, but the dancing duo could have promoted a product as harmless as Doublemint chewing gum.

Though the five-minute video was breathtakingly deaf, “The Hard Sell” suggests it made perfect sense given Insys’ damn business model. Led by Indian-born billionaire and company founder John Kapoor, sales executives identified a few dozen US doctors and nurses with a history of prescribing large amounts of opioids. The company then paid tens of thousands of dollars each to prescribe Subsys as part of a bogus speaker program. Insys employees dubbed the amazing prescribers “whales.”

The U.S. Food and Drug Administration approved Subsys in 2012 to treat a relatively small group of people: cancer patients who are already taking opioids like OxyContin around the clock but still suffer from what is known as breakthrough pain. These patients needed help fast. Subsys competed with several other fentanyl-based drugs made by competing pharmaceutical companies for the niche market.

But the whales bribed by Insys prescribed Subsys for everything from back pain to migraines. Off-label prescribing by doctors is legal and common, but it is illegal for drug companies to encourage the practice. “The reason for doing this is to determine what is safe and appropriate for a patient. A highly qualified physician should have leeway to deviate from FDA guidelines, but a drugmaker should have no leeway at all given their apparent bias,” writes Hughes.

Not only did Insys encourage off-label prescriptions, it did little to hide the fact that it was using payouts as an incentive. One of the government’s most damning exhibits in the process was a company spreadsheet that Kapoor had subordinates create over their strong objections. It showed the ROI, or return on investment, that the company received from each “speaker” for every dollar Insys paid the doctor or nurse.

“In other words, he wanted a written analysis of whether the bribes worked,” Hughes writes.

Several Insys executives came from competing drug companies with similar speaker programs and were not reluctant to pay prescribers. But they knew better than to write down an ROI or email a prescriber as a “very dodgy pill grinder,” like an Insys employee did.

Subsys wasn’t cheap. A typical prescription in 2013 ranged from $3,000 to $17,000 per month, depending on the dosage. Medicare paid over $70,000 for 10 months of care for a patient prescribed by a Michigan doctor who was arrested by federal authorities and became a cooperating witness against Insys executives.

Given the high cost of Subsys and the fact that it was approved to treat breakthrough cancer pain, Insys faced reluctance from health insurance companies to cover the costs. So the drug company set up a “reimbursement center” where Insys employees posed as doctors’ office workers and called insurers to say patients were being treated for cancer pain when they weren’t.

Vivid portraits of key executives are incorporated into The Hard Sell. Perhaps most intriguing is Alec Burlakoff, the unashamed if brilliant pharmaceutical sales veteran behind the speaker program, who wore the Subsys spray bottle costume in the rap video. (He pleaded guilty before trial and became a government witness, sentenced to a reduced sentence of 26 months.)

The book also deftly introduces several attorneys in the case, including Assistant US Attorney Fred Wyshak Jr. He knew little about healthcare fraud but much about extortion, having helped prosecute the notorious James “Whitey” Bulger . Sounding like someone the average juror might know in the neighborhood, Hughes writes that Wyshak “presented the defense’s arguments as finicky technicalities that he would counter with some plain language and a ‘let’s cut the crap’ tone.” “

If there’s one element that falls relatively short, it’s the patients who became addicted to Subsys. While no one is claiming that the pain reliever played anywhere near as big a role as OxyContin in the opioid crisis, I wanted to read about people who took it for non-cancer pain and became addicted to it.

Still, “The Hard Sell” is hard to beat as a compelling story about a drug company’s ruthless efforts to turn pain into a profit.

THE HARD SELL: Crime and Punishment at an Opioid Startup

By Evan Hughes

Doubleday, 288 pages, $28.95

Jonathan Saltzman reports on life sciences at The Globe.

Jonathan Saltzman can be reached at jonathan.saltzman@globe.com.


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