How an opioid startup's carelessness got its executives in trouble : The Indicator from Planet Money Insys Therapeutics was an opioid startup that made lots of money for its addictive nasal spray. Today, we hear from Evan Hughes, author of the book Hard Sell: Crime and Punishment at an Opioid Startup, on how the company's carelessness led to its ultimate downfall.

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This is THE INDICATOR FROM PLANET MONEY. I'm Stacey Vanek Smith.

The opioid epidemic has been raging for decades in the U.S. Opioid overdoses are now one of the top causes of death among Americans ages 18 to 45. A bunch of drug companies and doctors have been accused of aggressive marketing and overprescribing the drug.

And a new book gives us a window into exactly how this happens. "The Hard Sell: Crime And Punishment At An Opioid Startup" explores one drugmaker, a small startup, and looks at how this company marketed its powerful opioid and became a Wall Street sensation, and then how the company fell apart and its top executives ended up in jail. We talk with author Evan Hughes about the business of opioids after the break.


VANEK SMITH: Evan Hughes, author of "The Hard Sell," thank you for joining us. So your book centers around this little company Insys. And they had this one drug, Subsys, which was a liquid opioid sold in a little spray bottle 'cause you'd spray it into your mouth. It was extremely powerful. In fact, it was developed for end-of-life cancer patients who were already on pain medication but who were experiencing what's called breakthrough pain and just needed something very, very powerful and very fast-acting. So tell us about Subsys.

EVAN HUGHES: That's right. So the idea is, get the drug into the system, quell that pain and address it. The problem is when you have patients who the drug is not intended for - people with moderate and chronic back pain or neck pain - the drug is really so potent and so liable for abuse and addiction or misuse, it's really a recipe for disaster.

VANEK SMITH: There is this interesting turning point in the book, and it has to do with how the drug is going to be marketed. As John Kapoor, the CEO, is sort of putting together his team around this drug, it seems, like, very intentionally makes a decision that sort of the cancer patient target be removed from the marketing and also that the sort of quickness of the drug that that becomes sort of super emphasized. It seems like there is sort of a moment of the CEO kind of making a call that it's going to be marketed maybe more widely than it was intended.

HUGHES: Yeah. I mean, I think John Kapoor had invested a tremendous amount of money in bringing this drug to market, so he had a tremendous amount at risk. And early on, the drug was not really succeeding, and he wanted to be more aggressive.

What you see, what I found in my reporting in this book, is that the system they were living in was already constantly pushing the bounds of what is allowed in pharma, sometimes past those bounds in order to market the products. And in order to compete, they were going to have to go out and chase the same doctors who were dubious doctors, and they were going to have to offer them something a little bit better than the competition did.

VANEK SMITH: There are people called drug reps, drug representatives, that the drug companies hire to sort of, I guess, inform doctors about a drug and encourage them to prescribe it.

HUGHES: Right.

VANEK SMITH: What are some of the boundaries that were being pushed at the time Insys enters this market, and, like, how do they push even further?

HUGHES: So drug companies blanket the country with sales reps who are assigned to territories and visit them, and they make their pitch.

VANEK SMITH: And this is, like, all drugs, right? This is, like, heart medication and...

HUGHES: Absolutely right. And when you're a patient and you're sitting in the doctor's office, you might have seen these well-dressed people come in, you know, hauling their valise.

VANEK SMITH: (Laughter).

HUGHES: And they're pitching their drugs to doctors. But, you know, the question is, how do you stand out from the competition? So what do companies do? You know, they use flirtation. They use moneymaking opportunities.

VANEK SMITH: Like speaking gigs for the doctors and things like that.

HUGHES: Exactly. One of the boundaries is the drug companies are not allowed to promote a drug for so-called off-label uses, meaning uses that are not specified and approved by the FDA. So Insys was not supposed to be marketing this drug for anyone other than breakthrough cancer pain patients. But those rules are constantly broken. It's the reality.

What Insys did and what their competitors did, frankly, is target doctors who had very few cancer patients to begin with. They were targeting people who were prolific prescribers of all opioids.

VANEK SMITH: I was very surprised at the small number of doctors that were considered sort of the core group. I think it was, like, just a couple dozen doctors. And it seemed like there was this idea, if you can get these guys prescribing it, then the drug will really take off.

HUGHES: That's right. So what they did is they signed them up for these speaking programs that - in theory, they were supposed to be educational, peer-to-peer marketing, where one doctor tells another doctor about the benefits of the drug, speaks to a group of people at a restaurant.

But really, within Insys, it was a pretext. The speeches really didn't matter. Often, there were no attendees or one attendee. Really, what was happening was Insys was just taking them out to dinner and paying them for it.

VANEK SMITH: And how much money would we be talking about?

HUGHES: Some of these doctors made, you know, over $300,000 just on these speaking dinners.


HUGHES: Yeah - over time. But what I found is that the story there is really that Insys was not so different from its competitors. What made them different is they were reckless. They left evidence of what they were doing. It's like that rule in "The Wire" that you don't take notes on a criminal conspiracy.

VANEK SMITH: (Laughter) Yeah.

HUGHES: And they took notes. So reps were just, like, writing emails that were like, yeah, this guy's a pill mill doctor. He's totally irresponsible. He's lazy and inattentive, and I'm going to keep going back.

VANEK SMITH: He's our superstar.

HUGHES: Right. And then at the top of the company, they actually made spreadsheets of, like - it was called an ROI report, return on investment. So it was like, here's how much we're paying this doctor, and here's how much we're getting back from him in prescriptions, which just, like, spells out the quid pro quo that is illegal.

VANEK SMITH: I mean, opioids were and definitely still are, like, a hugely profitable industry. I mean, you spent years working sort of at the mechanisms of this. Like, what did you think as you were looking into this?

HUGHES: Well, one thing it makes you think about is, you know, what the system rewards and what the system incentivizes. You know, one of the things that the company did was they broke down doctors into deciles according to how much of competing drugs they prescribed. So who are the most prolific prescribers? And then they went after the top people. And now, if you think of it in terms of markets in any other product, it's sort of logical, right?

VANEK SMITH: Right. If you're selling, like, ice cream, you're like, OK, which grocery stores sell the most ice cream? Let's target them. Yeah.

HUGHES: Exactly, exactly. So we're going to send our rep to the big grocery stores, not the corner guy. Well, what does that mean when you have opioids? You know, you have a system where, you know, does it really make sense to reward companies that are most successful in persuading dubious doctors to prescribe a drug like this?

VANEK SMITH: There have been some other companies that prescribed opioids and made opioids. Where is this industry now as opposed to when you were writing the book?

HUGHES: Well, opioids have come under a lot more scrutiny over time, and now there's just a ton of litigation. But in this case, it kind of broke the mold because these executives were charged with crimes as individuals.


HUGHES: They were taken to court and sent to jail. So it's an example of true accountability for those at the top. And, you know, in the Purdue Pharma case, no one's gone to jail from Purdue Pharma, and it's likely that no one ever will.

It's like you're in a 55-mile-an-hour speed limit zone, and that speed limit is designed to protect patients. And everyone in the industry is going 75. And Insys went 85, so they got caught. But does the fact that they got ticketed - does that mean that the competitors are going to stop going 75? I'm not sure that it does.

VANEK SMITH: Evan Hughes, author of "The Hard Sell," thank you.

HUGHES: Thanks so much, Stacey.

VANEK SMITH: This episode of THE INDICATOR was produced by our senior producer Viet Le and fact-checked by Corey Bridges. THE INDICATOR's edited by Kate Concannon and is a production of NPR.


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