Opioid makers have been accused—and in many cases convicted—of doing all sorts of shady things to get people on highly addictive, often deadly opioid pain medications and spurring the devastating epidemic the country is now facing. They’ve allegedly greased doctors into writing unnecessary prescriptions, hidden and misled everyone on the drugs’ addictiveness, and looked the other way as large orders of opioids made their way to the black market.

But an investigation led by Senator Claire McCaskill (D-Mo.), the top-ranking Democrat on the Homeland Security and Governmental Affairs Committee, adds a new seedy tidbit to the list: posing as doctors' offices and straight-up lying to insurers to get deadly, powerful opioids covered for patients who don’t need them. In an audio file and report (PDF) released Wednesday by McCaskill, that’s exactly what you can hear a representative of Insys Therapeutics doing.

In the recording, the Insys rep is working to circumvent a so-called “prior authorization process” that insurers use to weed out unnecessary or abusive prescribing. In this case, the Insys rep wanted to get the Insys drug, Subsys, approved and covered for a patient in New Jersey named Sarah Fuller.

The problem was that Subsys is an incredibly powerful and dangerous fentanyl opioid, only approved by the Food and Drug Administration for use by cancer patients with “breakthrough” pain. That is pain that is unresponsive to other powerful opioids. Fuller had back and neck pain and fibromyalgia—not cancer or intractable pain from it. She also had a history of addiction to narcotic drugs.

Despite knowing this, Fuller’s doctor, Dr. Vivienne Matalon of Cherry Hill, New Jersey, had been prescribing her opioid medications for pain management—namely OxyContin and Percocet—since 2014. But, in January 2015, Matalon and Fuller had a meeting with an Insys representative to discuss her switching to Subsys, which costs more than $20,000 per month.

It was in that month that an Insys rep called her pharmacy benefit manager to try to get Fuller’s Subsys prescription covered. Initially, her insurer denied coverage of the “off-label” prescription.

In the call, the Insys rep repeatedly and strongly suggested that she was employed by Matalon and that she was calling from her doctor’s office. She then equivocated and dodged answers to get the benefit manager to think that Fuller had breakthrough cancer pain.

Here’s the audio file (mp4) and the transcript of the important bit (~4:45):

PBM: Hello, Gina? Hi, Gina, thanks for holding, I appreciate your patience. So is this initial or continuing therapy? Insys rep: This is initial. PBM: OK, and what is the diagnosis for the patient? Insys rep: Uh, let me look here…[mumbling]… medication is intended for the management of breakthrough cancer pain. The doctor is treating the patient for breakthrough pain with a diagnosis code of 338.29 [chronic pain]… PBM: 338..? Insys rep: 338.29, yeah and 338.4 [chronic pain syndrome] PBM: And did you say 338.4 also? Insys rep: Yes PBM: Thank you. [pause] Is it also for the breakthrough cancer pain or not? Insys rep: Well, there’s no code for breakthrough cancer pain. PBM: Yeah, and that’s fine. I typed out the description. I just wanted to make sure that I heard you correctly. Insys rep: It’s for breakthrough pain, yeah. PBM: Good. Ok.

According to court documents filed by Fuller’s family, Fuller died on March 25, 2016, “due to an adverse reaction to prescription medications.”

In a statement, McCaskill explained that this was unlikely to be a unique situation, saying:

“There is extensive evidence that Insys aggressively pressured its employees and the entire medical system to increase the use of a fentanyl product during a national epidemic that was taking the lives of tens of thousands of Americans a year in order to make more money—it’s hard to imagine anything more despicable. Their attempts to manipulate the prescription approval process for this drug appear to have been systemic, and anyone responsible for this manipulation deserves to be prosecuted.”

McCaskill also released a letter from Insys’ new president and CEO, Saeed Motahari, in which he emphasized that the company has gone through a massive overhaul, reshuffling executives and turning over more than 90 percent of its staff. He joined Insys in mid 2017 and is a former executive of Purdue Pharma.

“Like you and your staff,” he wrote, “I was concerned about certain mistakes and unacceptable actions of former Insys employees.” He said the company has since put new programs and ethics standards in place to correct problems. “We passionately believe that the company has taken steps to ensure that we will not repeat the mistakes of the past.”

Insys and its former executives face several federal, state, and civil lawsuits related to its opioid medications and their distribution.

The Senate committee’s investigation continues. McCaskill has expanded it to include “documents and information from opioid manufacturers Mallinckrodt, Endo, Teva, and Allergan, while a request to McKesson Corporation, AmerisourceBergen Corporation, and Cardinal Health, Inc., focused on their distribution of opioid products.”