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 .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,trimming marijuana plants 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. Because high rates of cocaine and methamphetamine use have been noted among younger heart failure patients and heart failure due to stimulant use may have a reversible component,targeted preventive and treatment efforts for young patients with drug use disorder may reduce the burden of heart failure. There is a paucity of literature investigating tobacco and substance use disorders in heart failure patients especially amongst racial/ethnic subgroups. While Native American race was associated with increased risk of alcohol use disorder, these patients also had high rates of tobacco and drug use disorders. Recent data from the National Survey on Drug Use and Health shows that American Indians or Alaska Natives have higher prevalence of tobacco use and cigarette smoking than all other racial/ethnic groups.38 Black race was associated with substance, alcohol, and drug use disorder. Cocaine use disorder was highest among black heart failure hospitalizations, while amphetamine use disorder was highest for Asian/PI heart failure hospitalizations. A prior study of 11,258 heart failure patients from the ADHERE-EM database found that self-reported illicit drug use with cocaine or methamphetamines was associated with black race compared to Caucasian.Black men and women present with heart failure at a younger age and have the highest age-standardized hospitalization rates compared to other race/ethnicities in the US.34 Addressing underlying substance use disorders in black patients may reduce the burden of heart failure attributed to substances and reduce hospitalizations. Conversely, Asian/PI males and females have the lowest hospitalization rates for heart failure compared to other races in the US. However, the Asian/PI population in the US is rapidly growing with high rates of amphetamine use,which may contribute to future heart failure hospitalizations.
Geographically, the Pacific region stands out for high rates of substance use disorder, especially drug use disorder. Data from NSDUH reports high prevalence of past-month illicit drug use by individuals 18 years or older within Pacific states.Patterns of use in heart failure patients may mirror those of the general population. Providers should be aware of types of substance use prevalent in their region. Rates of tobacco and substance use disorders were higher for patients of lower socioeconomic status as represented by payer status and median household income quartiles. Socioeconomic factors mediate differences in tobacco and substance use disorders based on race/ethnicity. While we cannot adjust for complex community stressors predisposing to tobacco or substance use disorders, evaluating community risk factors for tobacco and substance use disorders, such as density of tobacco stores,16 and identifying vulnerable groups may help develop preventive and treatment strategies, reducing observed disparities. Tobacco and substance use disorders in heart failure patients have implications for the broader health system. Substance use leads to increased costs from decreased productivity, healthcare costs, and crime.Tobacco,alcohol,and cocaine use are associated with increased readmission risk in heart failure patients. Screening for tobacco and substance use disorders has historically been deficient in primary care, emergency room, and hospital settings;despite efforts to improve screening, rates are likely under-appreciated. Heart failure patients who actively smoke but are attempting to quit may be coded with a different ICD-9-CM code than tobacco use disorder, further underestimating numbers.Tobacco and substance use disorders may have even larger negative effects on the healthcare system than currently reported. A violation of expectations produces a prediction error, a learning signal by which organisms update current understanding and knowledge of expectations. The primary neural locus implicated in violations of expectations is the ventral striatum , which undergoes significant development during adolescence, a period marked by sensitivity and responsivity to social feedback and reward.
The VS demonstrates increased activation for reward and reward prediction errors in this age group compared to other age groups. Importantly, the VS is also recruited when adolescents take risks and are in the presence of their peers. While a few studies have examined social violations of expectations in adults, to our knowledge, none have examined social violations of expectations in adolescents. The goal of this dissertation was to implement novel, ecologically valid designs to determine whether neural responses to realistic social feedback from a friend was associated with a common risky behavior, substance use, in adolescents. We found that adolescents recruited the VS for positive social violations of expectations compared to negative violations of expectations, and were happiest when their social expectations were met . We found that adolescents who recruited the VS more for violations of expectations reported greater substance use,vertical farming units while adolescents who recruited the VS less for violations of expectations reported lesser substance use, increased susceptibility to peer influence, and were more susceptible to peer influence in an experimental manipulation. Taken together, this body of work suggests adolescents who are more attuned to social cues from peers require smaller expectancy violations to experience reward; while those who engage in increased social risk taking require greater expectancy violations by comparison to experience reward. Implications of this work are discussed with regard to determining which adolescents are most likely to take greater social risks, based on their VS response to social violations of expectations. The ability to predict daily occurrences is beneficial and adaptive . For example, when deciding whom to ask to prom, a teenager might consider his current relationship status and prior interactions with a girl so he can expect with greater certainty that she will accept his offer. A violation of expectations is an unprecedented experience, and one that changes future behaviors and the expectations of future occurrences. If the girl unexpectedly rejects the teenager, he may be more hesitant to approach her again in the future. The experience of this violation of expectations might change his future behavior to include considering whether another potential prom date already has a date prior to asking her. Prediction Error A violation of expectations leads to a prediction error—a learning signal that is the calculated difference of an event’s outcome minus its expectation. Prediction errors have been examined extensively in behavioral reinforcement studies. This is evinced in a classic example: once a repeated presentation of a stimulus is conditioned to elicit a response for the receipt of a reward, a pigeon learns to peck each time the stimulus is presented to continue to receive the reward. This behavior continues even after the reward is no longer presented, producing a prediction error in the pigeon, whereby the presentation of the stimulus yields pecking, but no receipt of reward . Subsequently, the pigeon demonstrates a changed timing and increased effort of its pecking, suggesting it has learned that by pecking it will receive a reward. To characterize neural responses to prediction error, researchers have examined changes in the signaling of dopamine , a neuromodulator critical in reward receipt and reinforcement learning . Research by Schultz and colleagues assessing variability in prediction error revealed that when monkeys expected juice but did not receive it on schedule, there was decreased DA signaling, suggesting a negative prediction error. When monkeys were not expecting juice and received it, there was increased DA signaling, suggesting a positive prediction error. When the monkeys expected juice and received it, there was little change in the DA neurons, suggesting expectations were met . This seminal body of work suggests variability in reward modulation in dopaminergic regions is dependent on the valence of prediction error. Similar research assessing whether DA neurons encode prediction error found increases in midbrain DA firing when monkeys accurately predicted receipt of a reward compared to inaccurate predictions .
By using an interval-based reward saccade task, Bayer and Glimcher concluded that reward prediction errors could be tracked by measuring the increased firing rate of DA neurons—an occurrence that is indicative of reinforcement learning. The neural basis of prediction error with primary reward in humans supports research in non-human primates, such that humans also demonstrate increased activation in dopaminergic brain regions in response to positive prediction errors, and decreased activation in response to negative prediction errors. The valence of a violation of expectations has been examined neurobiologically in humans. When the violation is positive, researchers find greater activation of the ventral striatum , while a negative violation of expectations is associated with activation in the amygdala , and the insula. Classic studies assessing the magnitude of prediction error in animals have demonstrated that when aviolation of an expectation is large , there is greater dopaminergic activation compared to when it is small . Research in humans has also demonstrated differential activation in error detection and reward circuitry by violation magnitude. The distinct responses in dopaminergic activation to violations of expectations demonstrate how sensitive humans and non-human animals are to this learning signal. It is perhaps unsurprising then, that prediction error is implicated in reward and learning-motivated behaviors, such as substance use and addiction. Substance Use Research on reward prediction errors has indicated that while receipt of primary rewards elicit a dopaminergic response, the chemical compounds associated in drugs of abuse and the drug receptors they act on can produce an even greater response by comparison . Addiction research has indicated that dopaminergic activation in response to receiving rewards produces prediction errors that override decision-making systems . In this case, using an addictive substance produces a surge in dopamine and a large reward prediction error, leaving the user with an increased desire to reuse the substance to obtain the same rewarding sensation . Further examination of reward prediction errors in response to using a drug of abuse suggests that understanding how reward is processed can aid in identifying who may be more at risk for addiction. A review by Hyman and colleagues suggests that individuals who have more associations to the cue of the reward are at a greater risk for reusing and relapsing , as the associations cross multiple fields of dopaminergic innervations. Across multiple studies, researchers find that individuals who demonstrate increased ventral striatum response in association with receiving a reward are more likely to engage in risky behaviors.