Medical Board Places Los Angeles Psychiatrist Warden Emory on Probation over Excessive Controlled Substance Prescribing

September 26, 2023

On September 2, 2022, the Medical Board of California revoked the license of Los Angeles psychiatrist Warden Emory. The revocation was stayed, and he was placed on five (5) years’ probation for gross negligence, repeated negligent acts, and failure to maintain adequate and accurate medical records in the care and treatment of multiple patients. Limits were placed on his practice, and he was subject to fines.  

Emory treated four patients from 2012 to 2018. During that time, he regularly prescribed high doses of opioids and benzodiazepines, and there was no discussion of an opioid agreement or the potential risk of combining opioids and benzodiazepines documented in any of the patient’s medical records.

Further, Emory failed to conduct risk stratification urine testing or regular review of Controlled Substance Utilization, Review and Evaluation Systems (CURES).   

Emory failed to make any significant effort to assure that the patients were not diverting the controlled substances prescribed. He did not do toxicology screenings not only to look for illicit or unprescribed substances but also to make sure the prescribed medications were actually being taken.   

Patient 1: He regularly prescribed high doses of opioids and benzodiazepines; however, there was no discussion of an opioid agreement or the potential risk of combining opioids and benzodiazepines documented in the medical record. In addition to the above accusations, his evaluation of respiratory depression risk related to the combination of opioid and benzodiazepine by solely evaluating electroencephalogram (EEG) data is not consistent with the standard of care.

Patient 2: He regularly prescribed opioids, benzodiazepines, and muscle relaxants. There was no discussion with the patient of an opioid agreement or the risks of combining opioids, benzodiazepines, and ketamine. The patient reported that he would have likely committed suicide without Emory’s help; however, there was no further documentation about a discussion of suicidality with this patient nor was there any discussion of how the patient should dispose of the ketamine he was no longer using. This was an extreme departure from the standard of care.

Patient 3: A 68-year-old female at the time, from May 2015 until August 2018. Patient 3 owned a jet and would travel back and forth between Arizona, Michigan, and Los Angeles. Her living arrangements posed a potential risk of medication misuse or diversion. She had both financial and physical means to readily and regularly travel out of state and pay cash (which was how she paid Emory) for essentially untraceable visits with physicians whose out-of-state prescriptions would not show up on a CURES report, even if he had checked them regularly, which he did not. There was no clear assessment of the risk of substance abuse, misuse, or addiction. This was an extreme departure from the standard of care.

Patient 4: He failed to consult with a cardiologist or any other physician regarding the patient’s known tachycardia. Emory performed an EEG that included a single channel of electrocardiogram (EKG); however, its diagnostic utility is limited and is not intended as a replacement for a 12-lead EKG. This was a departure from the standard of care. 

Source: Decision in the Matter of the Accusation Against Warden Hamlin Emory, M.D., Physician's and Surgeon's Certificate No. C31807, Case No. 800-20197-039397, Medical Board of California, September 2, 2022.