It is important to note that sleep hygiene alone is not efficacious for chronic insomnia. CBT-I should be implemented by a trained provider or web-based program supported by clinical data. In-person CBT-I options are often limited by an insufficient number of trained clinicians, cost/insurance barriers, and time intensity . Recent studies support the use of validated web-based CBT-I programs , group formats, and condensed versions, such as brief behavioral treatment for insomnia . Behavioral treatments can also be implemented in patients who are concurrently receiving sleep aids .Chronic insomnia disorder is characterized by perceived difficulty initiating or maintaining sleep or waking up earlier than desired with difficulty returning to sleep, coupled with daytime impairment. It is a common condition in the United States, with an approximate prevalence of 10–24% . In addition to being a source of emotional distress, chronic insomnia can create problems with mood and cognitive function and can lead to increased risk of automobile accidents, increased healthcare costs, perceived poor health,horticulture solutions and loss of productivity or errors in the workplace . Insomnia is frequently persistent if left untreated. Chronic insomnia, by definition, lasts for more than 3 months, but 56–74% of patients will continue to have insomnia at 1 year and 46% of patients have insomnia for at least 3 years .
The mainstay of treatment for chronic insomnia is CBT-I when available. There is moderate existing evidence to suggest that CBT-I improves sleep outcomes and has limited potential for harm . Little is known about the effects of using hypnotic medication on a long-term basis , yet many patients remain on pharmacologic treatments for insomnia beyond what can be thought of as an acute period; ~2.5% of the U.S. population receives hypnotics for insomnia, and 25% of that group has been on nightly treatment for 4 months or longer . The initial guidelines for pharmacotherapy in chronic insomnia were based on short-term hypnotic use, with the mean duration of clinical trials being 1 week. Two more recent trials have examined the use of hypnotic medications over a 12-month period, and as a result, eszopiclone and zolpidem extended release are now FDA approved for long-term use . Many providers and patients remain hesitant to use hypnotics on a long-term basis because of fear of potential health-related consequences. One matter of particular concern to patients is the association of long term hypnotic use with neurodegenerative diseases, mainly Alzheimer’s dementia. Multiple prospective and retrospective studies have linked long-term benzodiazepine and nonbenzodiazepine hypnotic use with dementia . Long-term hypnotic use has also been linked to increased mortality, cardiovascular disease, psychiatric disorders, and falls . Although alarming, support for these concerns comes mainly from association studies, and furthermore, these possible risks have not formally been studied against the risks of untreated insomnia. Insomnia with short sleep, defined as a duration of less than 6 hours, has been shown to increase risk of hypertension, acute coronary syndrome, and mortality .
There is also evidence that insomnia and sleep fragmentation may be risk factors for neurodegenerative diseases, including Alzheimer’s disease . Recently, several hypnotic agents, including doxepin , orexin antagonists, suvorexant, and lemborexant have been approved by the FDA for the treatment of insomnia. Current data examining their safety and efficacy in the long term are sparse. In conclusion, for the treatment of chronic insomnia, CBT-I should be first line when available, but long-term pharmacotherapy may be appropriate in a select group of patients. We need more rigorous and dedicated research to fully elucidate the safety of long-term hypnotic use, but one must also consider the consequences of untreated insomnia with respect to quality of life and risk of morbidity and mortality. A careful risk– benefit analysis should be assessed for each patient, and the provider must engage in shared decision-making when considering the long-term use of hypnotics for chronic insomnia .Heart failure is the fourth overall principal diagnosis and first among cardiovascular conditions as the reason for hospitalization in the U.S.1 Heart failure is a prevalent condition with several preventable etiologies including uncontrolled hypertension or ischemic heart disease.Behavioral risk factors such as tobacco, alcohol, and drug use are known to contribute to heart failure incidence.Alcohol,cocaine,and amphetamines have cardiotoxic effects. Drug overdose death rates in the U.S. are rising, especially in younger persons.The burden of active tobacco and substance use disorders among hospitalized heart failure patients in the U.S. has not been well described. Nationally representative administrative data facilitates understanding the burden of tobacco and substance use disorders among heart failure patients and its potential influence on health outcomes.
Vulnerable populations, including patients from racial/ethnic minorities or lower socioeconomic status, may be at increased risk of developing tobacco or substance use disorders for multiple reasons including social stressors, lack of economic opportunity, and community factors.Identifying heart failure patients with tobacco or substance use disorders is critical to developing treatment strategies to address observed cardiovascular health disparities. We describe the national burden of heart failure and comorbid tobacco or substance use disorder among hospitalized patients in the U.S. We used data from the 2014 National Inpatient Sample to describe diagnosis rates of tobacco and substance use disorders among hospitalized heart failure patients and examined demographic groups that may be at higher risk for these disorders. The NIS dataset provides hospital administrative data through the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project. It contains approximately 7 million weighted hospital discharges representing 35 million inpatient hospitalizations.The NIS unit of analysis is a discharge; therefore, read missions are not identified. The sample is drawn from forty-four states and the District of Columbia, covering more than 96% of the U.S. population. A 20% stratified sample is obtained from 4,411 U.S. community hospitals. All insurance payer sources are included. Survey weights are provided to obtain national estimates for relevant statistics.Heart failure was defined by any International Classification of Diseases, Ninth Revision Clinical Modification code that mentioned a heart failure syndrome . A primary heart failure hospitalization was defined as any heart failure ICD-9-CM code used as the first listed discharge code, consistent with prior publications.20,21 Patients less than 18 years were excluded. Race/ethnicity was classified as white, black, Hispanic, Asian/Pacific Islander , or Native American as captured by administrative hospital data. Additional demographic factors included age, sex, payer source, geographic Census division, and median household income based on zip code. Substance use disorder was defined as any alcohol or drug use disorder, excluding tobacco, which was a separate outcome. Tobacco, alcohol, and drug use disorders were defined using Clinical Classifications Software and ICD-9-CM codes .Drug use disorder was sub-divided into cocaine, cannabis, opioid, amphetamine, psychotherapeutic , hallucinogen, and other use disorder categories .Overall and for each tobacco and substance use disorder category, we estimated the national proportion of hospitalized heart failure patients and provided descriptive statistics for patient characteristics, select comorbidities, hospital length of stay, and inpatient mortality. We next stratified heart failure hospitalizations by sex and other demographic factors . For each stratum, we reported the percent of patients in each tobacco or substance use disorder category. Tobacco and substance use disorder rates were age-standardized using the 2000 US Standard Population,grow benches per Center for Disease Control and Prevention recommendations.To evaluate demographic factors associated with each comorbid tobacco or substance use disorder category, we used logistic regression models accounting for clustering and non-linear age-adjustment using multi-variable fractional polynomials.Selection of best-fit multi-variable fractional polynomial models used a closed-test algorithm.This curvilinear adjustment was used to reduce residual confounding that may arise secondary to model misspecification using age as a single linear term.All estimation procedures were performed with appropriate NIS survey weights to account for sampling design, and all results are presented as the weighted national 2014 hospitalized population. Analyses were performed in STATA 15.1 . Institutional IRB provided an exemption for this research.There were 989,080 heart failure hospitalizations in the U.S. in 2014 of which 15.5% had documented tobacco or substance use disorder. Tobacco use disorder was found in 12.1% , substance use disorder in 6.2% , alcohol use disorder in 3.5 % and drug use disorder in 3.5% . Both tobacco and substance use disorder were documented on 2.8% of heart failure hospitalizations, while both alcohol and drug use disorder were found in 0.7% .
In the overall heart failure cohort, mean patient age was 72.0 , and females comprised almost half of the hospitalizations. The majority of heart failure hospitalizations were for patients age 65 or older , of white race/ethnicity , and with payer source of Medicare . Demographic patterns of the cohort with no tobacco or substance use disorder mirrored that of the overall heart failure cohort. Tobacco use disorder patients were younger than the overall heart failure cohort and 36.0% female . Tobacco use disorder was more common among males than females across demographic subcategories . Rates were highest for both sexes between ages 45 and 55 . Native American males had highest age-adjusted rates , while white and Native American females had highest age adjusted rates . Tobacco use disorder rates were highest in the East South Central region and for payer status of no charge , self-pay , or Medicaid . Rates of tobacco use disorder increased as median household income decreased. Heart failure hospitalizations with documented substance use disorder represented younger patients than the overall or tobacco use disorder cohorts and were 22.9% female . Substance use disorder diagnosis rates were highest for males 45 to 55 years of age and females <45 years of age . Native Americans had highest rates of substance use disorder when age-adjusted . Substance use disorder was highest for heart failure hospitalizations in the Pacific region, payer status of Medicaid, self-pay or no-charge, and for lower income quartiles. Alcohol use disorder was less common among female heart failure hospitalizations relative to tobacco and drug use disorder . Heart failure hospitalizations for those age 45 to 55 years had highest rates of alcohol use disorder . Alcohol use disorder rates were highest among Native Americans , the Pacific region , payer status of no charge , Medicaid or self-pay , and the lowest income quartile. Heart failure hospitalizations with drug use disorder were the youngest cohort and 29.1% female . Racial/ethnic minorities had higher representation among drug use disorder hospitalizations, as 44.9% of drug use disorder hospitalizations were for black race/ethnicity. Medicaid insurance and lowest quartile income was more prevalent among heart failure hospitalizations with drug use disorder compared to no use, tobacco, or alcohol use disorder . Cocaine was the most frequent substance-specific drug use , followed by other unspecified drugs , cannabis , opioids and amphetamines . Drug use disorder was generally most common for both sexes age <45 years. For males, highest rates of drug use disorder were for Asian/PI hospitalizations , while for females, highest rates were for black hospitalizations . Asian/PI males and females had highest rates of amphetamine use . Black males and females had highest rates of cannabis and cocaine use . The Pacific region had highest rates of drug use disorder . Medicaid hospitalizations had highest rates of drug use disorder overall and for cocaine, opioid, and amphetamine use disorders for both sexes. Those in the lowest income quartile had highest rates of drug use disorder overall and for most subcategories.Among national heart failure hospitalizations, 15.5% had comorbid tobacco or substance use disorders. Tobacco use disorder was most common at 12.1% overall, a rate similar to prior studies . For certain male heart failure subgroups, including those age 45 to 55 years, Native American race/ethnicity, and payer status of Medicaid, self pay, or no charge, our results show that approximately one-third of hospitalizations had tobacco use disorder. Tobacco use in OPTIMIZE-HF patients contributed to earlier age of decompensation requiring hospital admission.Quitting smoking may be as effective a treatment as prescribing ACE inhibitors, beta-blockers, and aldosterone inhibitors in improving survival.Drug use disorder was uncommon among older heart failure patients. The etiology of heart failure in advanced age is well established,largely due to coronary artery disease and poorly controlled hypertension. However, the pathogenesis of heart failure in patients under 40 years is less clear, with many patients diagnosed with idiopathic cardiomyopathy.Untreated drug use disorder may be responsible for heart failure in these young patients where the etiology remains unclassified, as we found high rates of drug use disorder in this population.