A pair of former pharmaceutical sales representatives took the stand Tuesday afternoon in the trial of Dr. John Patrick Couch and Dr. Xiulu Ruan in the first testimony linking the local pain physicians to an opioid drugmaker they’re accused of receiving kickbacks from.

Both Lacy Kambic Fortenberry and Natalie Perhacs were employed by Insys Therapeutics, a pharmaceutical company that developed and manufactured Subsys, a spray version of the powerful opiate fentanyl.

In December, six former Insys employees — including former CEO Michael Babich — were indicted by federal prosecutors in Massachusetts for an alleged conspiracy to bribe doctors across the country into widely prescribing Subsys despite its only approved use through the FDA being “breakout pain” in the patients with late-stage cancer.

Patients wait in line outside of Physicians’ Pain Specialists the day after the business proprietors, Dr. John Patrick Couch and Dr. Xiulu Ruan, were federally indicted.

In Mobile, Couch and Ruan were allegedly two of the doctors that, according to Fortenberry, were “valuable to the company.”

In fact, before the drug was on the market, Fortenberry said both doctors were known as some of the “highest prescribers” of other fentanyl medications, which made them and their practice — Physicians Pain Specialists of Alabama — a top target for the Insys sales team.

“Dr. Ruan knew some members of the company from before … through other companies they’d worked with,” Fortenberry said, adding that Ruan was cozy enough to reach out to the company directly.

Fortenberry was the sales representative assigned to Couch, though she also marketed Subsys to “pain management physicians and oncologists” in four southern states. However, unlike Couch, Ruan’s Insys sales representative dealt with him and only him — something Fortenberry said was unique in the company.

That salesman was Joseph A. Rowan, 43, who was one of the six ensnared by an indictment last month in Massachusetts. Fortenberry worked with and eventually for Rowan during her time with the company.

Other than sales, she also helped organize paid speaking events for physicians that were part of a Insys program that later became the alleged means of facilitating bribes to doctors. In Rowan’s indictment, those speaking gigs were described as “sham events” that were typically only attended by staff members and friends of the doctors.

In Fortenberry’s testimony, she said the program started as “educational” and “beneficial” but became a way to reward doctors who frequently Subsys prescriptions. Sales representatives were tasked with identifying doctors to be “speakers,” so Fortenberry said she saw how the company’s approach changed firsthand.

“By the end of my time with the company, speakers had to have clinical experience and be writing consistent prescriptions for Subsys,” she said. “[They were] doled out according to the amount of prescriptions that were written.”

Ruan and Couch were paid close to $220,000 by Insys in 2013 and 2014, though defense attorneys representing both doctors said they could have made a lot more money “sitting at their desks” than they could have giving speeches to other doctors.

During her cross-examination, Fortenberry also said Ruan was one of the earliest Insys speakers selected and agreed with defense attorney Dennis Knizley that Ruan was likely a top choice because he was “held in high esteem by his peers” and had multiple published works.

Like most people in sales, Fortenberry told jurors she was under pressure to move her company’s product, and during her testimony, described some of ways Insys would approach doctors about “writing more prescriptions” and at higher doses.

Alec Burlakoff — who was also indicted in December — was the former Vice President of Sales for Insys, and for at least part of her tenure, Fortenberry answered directly to him. On the stand, Fortenberry read through emails she exchanged with Burlakoff and Rowan.

In one, Burlakoff wrote that Ruan and Couch needed “to start pressing it,” which Fortenberry said meant prescribe more Subsys to their patients. She also said Couch was the top Subsys prescribers in her region.

Despite sharing a practice with Couch, though, Ruan was not considered to be in the same sales region because he dealt specifically with Rowan, whose indictment in Massachusetts mentions being assigned to market “to a single doctor” that isn’t identified in the document.

John Patrick Couch is one of two local doctors accused of improperly prescribing addictive opioid pain killers. (Dan Anderson)

In other emails, Fortenberry had to explain why Couch only wrote one prescription for Subsys in a week. She told them his numbers “wouldn’t be that low again” and she’d already received “three script promises for today and tomorrow” from Couch.

Defense attorney Jack Sharman also made use of Fortenberry’s old emails, one of which he used to suggest Couch prioritized his own medical judgment over Insys’ bottom line. It dealt with titration, which is a process of getting a patient to an appropriate dose of medicine.

When a superior asked in why Couch wasn’t using a method of titration preferred by the company in 2012, Fortenberry wrote, “he insists he is ultimately providing his patients the effective dosage of Subsys and will be continuing with his titration method.”

Or as Sharman put it, “Whatever the titration expectations of others might have been, Dr. Couch was confident in how he was handling it and would be using his titration method, not somebody else’s.”

Left, Dr. Xiulu Ruan arrives for an arraignment in federal court in May 2015.

Though she held the same job as Fortenberry, Perhacs was not employed at the same time, and in fact, she likely would have never gotten the job it weren’t for a “strong recommendation” from Ruan.

Perhacs pleaded guilty to anti-kickback violations in February 2016 and in a plea agreement said she was hired by Insys as a kickback to Ruan, whom she claims was “romantically interested” in her.

According to her testimony, Perhacs first met the doctors while looking for client recommendations for her sales job with Lincare in Mobile, though it wasn’t long before she started receiving emails from Ruan.

“I wanted to ask you a personal question, and hopefully you will not be offended,” Ruan wrote in one email. “Are you involved with someone now. It seems Dr. Couch really likes you? Are you involved with him now? Do you involve with him in the future? You don’t have to answer any of these if you don’t feel comfortable.”

Perhacs she was not then nor was she ever “involved” with either doctor during her time with the Lincare or Insys.

However, she said Ruan continued to email her — asking her to dinner on multiple occasions, offering to hire her as a “private coach” to help with his public speaking skills and ultimately to discuss finding a sales position for her in a pharmaceutical company.

In April of 2013, he found a position for Perhacs with Insys, though as their emails show, Ruan “talked [Rowan] out” of offering the same position to his girlfriend from the time in order to secure Perhacs’ hiring.

On the stand, Perhacs said she was hired because of her recommendation from Ruan, as she didn’t know anything about Subsys or fentanyl. In fact, she said her knowledge of the company’s products came from links Ruan emailed to her before her job interview.