This is somewhat less explosive after reading Empire of Pain, while at the same time being more brash and more satisfying in some ways. It's really hard to care that insurance companies are being defrauded when they are essentially defrauding all of us, but I guess that loss just gets passed to us consumers anyway. The amount of straight up lying going on here is mind-numbing. I love the idea of a pain med for breakthrough cancer pain, because morphine just isn't enough sometimes. But of course it has to be mismanaged to the point it can't exist. At least they get their just deserts this time around. ( )

> Instead of mentioning breakthrough cancer pain, he wanted reps to say Subsys had the same indication as the chief competitors, Cephalon’s Actiq and Fentora. That approach conveniently omitted the word “cancer” and steered clear of the inconvenient fact that Subsys was only approved for a relatively small group of patients. It also implied, without saying so, that Subsys was appropriate for non-cancer pain, because that was in fact the primary use for those two competing drugs, partly owing to Cephalon’s illegal off-label promotion.

> Data analysis had revealed that the patients on the lowest strengths of Subsys were the most likely to stop taking it. Clearly, Kapoor concluded, doctors needed to titrate up—move patients up to higher-strength prescriptions.

> The higher strengths of Subsys were more expensive, so reps naturally earned more on those scripts because their commissions were tied to the dollar amount. On top of that, Kapoor authorized an incentive structure where the bonus percentage was higher on the top two strengths, 12.5 percent instead of 10, an extra carrot for the sales force. In late 2012, if a doctor put pen to paper for one Subsys script at the highest strength, the rep would collect $1,830.

> In the last couple of decades, a number of major drugmakers have made an important change to their call-note systems. Now, reps don’t type anything at all. They just select from a series of drop-down menus, answering queries in multiple choice: How much time did you spend with the doctor? Which of the following product benefits were discussed? There is no place for the rep to engage in free writing, no opportunity to accidentally leave evidence of off-label promotion or spell out warning signs about the physician. The genius of the drop-down menu, in other words, is that every possible answer a rep can give is legally clean. — Insys failed to practice such self-protective measures.

> nothing that Insys did was truly new. Its leadership didn’t invent targeting decile 10 opioid prescribers and pushing higher doses. They weren’t the first to promote off label, nor to insert themselves into insurance decisions and fudge the facts to get to yes. And they didn’t come up with using speaker programs as a pretext to set up a quid pro quo. ( )