Mandana Khalili, MD, is Chief of Clinical Hepatology and Director of Clinical and Translational Research in Hepatology at San Francisco General Hospital, and directs the UCSF T32 Hepatology Training Program.

Mandana Khalili, MD

US drinking is falling for the first time since the COVID-19 pandemic, but heavy drinking is still rising among adults aged 50 to 64.¹ Hepatologists say 

 may be slow to follow the decline, particularly for that age group, women, and other populations already at higher risk.

"The patient in front of you is more likely to be a woman or someone in their 50s than a decade ago, more likely to have metabolic comorbidity, and more likely to present with cirrhosis rather than steatosis as the first diagnosis," Brian P. Lee, MD, MAS, a hepatologist and liver transplant specialist with Keck Medicine of USC, told HCPLive.

, and hit women, young adults, and American Indian and Alaska Native people hardest. Even with the recent dip, both drinking and alcohol-related cirrhosis deaths remain above 2018 levels.¹˒²

For Liver Awareness Month, HCPLive asked 4 liver disease experts where ALD is headed and what clinicians can do now, from asking every patient about alcohol to catching liver disease before cirrhosis and treating 

Will Alcohol-Associated Liver Disease Continue to Rise?

"I'd expect it to keep climbing," Brian Lee said when asked whether the burden of ALD will peak within the next 5 years. "Three things point that way. The lag between drinking and cirrhosis means the pandemic-era increase hasn't finished working through the population. The group still drinking more is the group in the window for disease. And metabolic risk is rising in the same patients, which raises the harm per drink even where drinking is flat."

Frances Lee, MD, assistant professor of medicine (liver diseases) at the Icahn School of Medicine at Mount Sinai and director of the Alcohol-Associated Liver Disease Program, described the combination of metabolic factors and alcohol as acting "like adding fuel to the fire."

Modeling supports the lag. A 2022 study projected that a single year of increased drinking during the pandemic would lead to 8,000 additional ALD-related deaths from 2020 to 2040, with only about 100 of them expected by 2023.³

Brian Lee said he is particularly concerned about adults aged 50 to 64, whose 

heavy drinking rose >36% from 2018 to 2024

"This is the group in which the combination of exposure and timing is most concerning," he said. "Fibrosis accumulates over decades, so a 55-year-old who increased their drinking in 2020 is often adding to damage that's already there rather than starting from a healthy liver. This is also the decade when cirrhosis and hepatocellular carcinoma most often declare themselves, and there's less physiologic reserve to absorb an insult."

"Cirrhosis and liver cancer in adults over 50 I'd expect to rise through the end of the decade," Brian Lee said. He was more cautious about younger adults.

"If younger adults' drinking stays below 2018 levels, I'd expect those acute presentations to ease sooner than the cirrhosis burden in older patients," he said. "That's a hypothesis rather than something this study can show, and doesn't account for co-factors of alcohol-associated liver disease that are changing in prevalence independent of alcohol consumption."

"Whether the overall burden peaks in five years or ten depends mostly on whether the 50 to 64 trend reverses, and there is no indication of that yet in the data," he said.

Some of the observed rise may also reflect better detection. Asked whether the increase among younger adults and women reflects more disease or better recognition, Frances Lee said it is likely both.

"I believe that both can be true. The rise in ALD is likely multifactorial: increased alcohol use in our society, metabolic features/syndrome in younger and more patients, and increased detection of ALD," she told HCPLive. "More evidence is needed to inform providers in their counseling to patients."

Why Alcohol-Associated Liver Disease Is Often Diagnosed Late

Part of the challenge is that liver damage rarely announces itself.

"The liver is actually a very resilient organ that will continue doing that work every single day, without any complaints, without any symptoms," Stevan Gonzalez, MD, MS, director of liver transplantation at Baylor Scott & White All Saints Medical Center in Fort Worth, Texas, said in an 

A 2024 study at one US academic primary care network found that more than half of patients with cirrhosis or hepatocellular carcinoma had a missed or delayed chronic liver disease diagnosis, and ALD was the most common cause among them.⁴

Gonzalez said catching these patients will take more than specialists.

"What we're recognizing is that chronic liver disease in the U.S. is vastly underestimated, and it's beyond what... just a specialist can do in terms of the general population, and that's where our primary care providers and our community-based health organizations are going to play a very important role in increasing awareness, education, and screening," he said.

He added that finding liver disease earlier matters because the damage is not always permanent.

"Even if a person does have evidence of advancing or progressive liver disease, it's reversible," Gonzalez said. "So you can actually avoid cirrhosis, and the liver can actually return to an improved function."

How Clinicians Can Screen for Alcohol Use and Liver Fibrosis

"What clinicians can do is to stop relying on patients to bring alcohol use up in conversation," Brian Lee said. "Alcohol use should be asked about at every visit, like smoking, with a validated screen like the AUDIT-C, and for patients where the history is uncertain there's now a biomarker, phosphatidylethanol, that gives an objective measure of intake over the prior 4 weeks."

The 2024 American College of Gastroenterology guideline on ALD recommends brief screening tools such as the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), and identifies the Fibrosis-4 score and transient elastography as the best noninvasive tests for fibrosis.⁵

 is a common blind spot. In CDC data, most adults reported being asked about alcohol at a checkup, but only about 38% were asked about binge-level drinking.⁶

"Current definitions of metALD and ALD account for chronic consistent alcohol intake, but binge alcohol intake has also been known to be associated with worsened liver outcomes," said Frances Lee, whose research presented at Digestive Disease Week 2026 linked binge drinking frequency to advanced fibrosis. "Binge alcohol intake may increase the risk of fibrosis progression in 

"The thresholds for heavy drinking are lower than most patients and a fair number of physicians assume, so being knowledgeable about those thresholds (≥15 drinks per week or ≥5 drinks on any given day for men and ≥8 drinks per week or ≥4 drinks on any given day for women) is important," Brian Lee said. "For women, it means using the sex-specific thresholds explicitly, since a patient told '14 or fewer drinks a week' is being given the wrong number."

Frances Lee noted that much about ALD in women remains unknown. "There is still so much to learn, though, as far as other features of sex differences, such as hormone levels, menopausal status, on the progression of ALD," she said.

Federal guidance no longer offers a number. The 

2025–2030 Dietary Guidelines for Americans

 replaced the previous daily limits with advice to "consume less alcohol for better overall health."⁷

Brian Lee said physician messaging also matters.

"Many patients, and some physicians, still believe a glass of wine a day is good for the heart," he said. "That idea came from observational studies that compared drinkers with abstainers who had often quit because they were already sick, and when that bias is accounted for, the protective effect largely disappears. The current evidence is that cancer and liver risk can begin even at low alcohol levels and rise with dose, and the message coming from physicians should reflect that. A patient who hears 'moderate drinking is fine' from their doctor has no reason to cut back."

The evidence on low-level drinking remains debated. A 2023 meta-analysis found no mortality benefit for low-volume drinkers,⁸ while a 2024 National Academies review concluded that moderate drinking was associated with lower all-cause mortality but higher breast cancer risk.⁹

"Most prevention messaging is built for young people, and the data suggest young people are already responding," Brian Lee said. "The group that needs it is 50 to 64, and they're largely invisible to it. Tailored prevention for this group looks like alcohol screening built into the visits they're already having, which are for blood pressure, diabetes, and cancer screening, with a fibrosis assessment attached when drinking is at or near threshold."

Integrating Alcohol Treatment Into Hepatology Care

Screening is only the first step. A randomized trial published in 

 in June 2026 tested a telehealth stepped alcohol treatment model in 157 patients with chronic liver disease and unhealthy alcohol use at safety-net and Veterans Affairs hepatology clinics. Patients received motivational interviewing by telehealth, and those still drinking at 3 months were referred to addiction medicine.¹⁰ The trial missed its primary endpoint, but stepped care led to significantly greater reductions in drinks per week.

"One of the most important findings was that the participants receiving the step care treatment had a significantly higher reduction in the amount of average alcohol intake," Mandana Khalili, MD, professor of medicine at the University of California, San Francisco, and chief of clinical hepatology at Zuckerberg San Francisco General Hospital, said in an 

. "Even reducing alcohol consumption short of complete abstinence is meaningful clinically in this population with chronic liver disease and is also consistent with a model of harm reduction."

"Rather than thinking of alcohol treatment as something that happens only in specialty addiction services, hepatology clinics themselves can play an active role in engaging patients in this type of evidence-based care," she said.

With follow-up near 90% in a population facing medical, socioeconomic, and access barriers, Khalili said patients were willing to engage. "This lets us know that chronic liver disease patients are receptive to discussing alcohol use and engaging in treatment if it's offered in patient-centered and accessible ways," she said.

She said motivational interviewing works best when clinicians tie cutting back to what patients care about, such as sleep, mood, family, or finances. "I think helping patients connect alcohol reduction with the goals that are personally meaningful to them increases their motivation, and it's much more effective in sustaining behavioral change," she said.

AUD Medications Remain Underused in Alcohol-Associated Liver Disease

When patients do meet criteria for AUD, "we have effective medications that are prescribed far less often than they should be," Brian Lee said.

In 2024, only 2.4% of US adults with past-year AUD received medication for it.¹¹ Patients with liver disease fared worse: in one claims study, AUD medication was prescribed to 14.5% of patients without ALD but only 2.3% of those with ALD cirrhosis.¹² In a survey of liver disease providers, 71% said they had never prescribed AUD pharmacotherapy, most often citing low comfort.¹³

That gap matters. In a cohort of 9635 patients with AUD, medication for AUD was associated with lower odds of developing ALD and, among those with cirrhosis, lower odds of decompensation.¹⁴

Turning Alcohol Screening Into Earlier ALD Intervention

For now, the tools clinicians already have may matter most. A prepandemic model projected that a strong intervention to reduce high-risk drinking could prevent about 299,100 ALD deaths from 2019 to 2040.¹⁸

"It means treating a heavy drinking history the way we treat a family history of colon cancer, as an indication for evaluation rather than counseling alone," Brian Lee said.

Khalili added that a clinician's role does not end with identifying the problem. Motivation, she said, "really is something that clinicians can actively help strengthen."

Editor's note: Frances Lee does not report any relevant disclosures. Gonzalez reports relevant disclosures with Mallinckrodt Pharmaceuticals, Salix, AbbVie, Gilead, and others. Brian Lee reports consulting for Gilead Sciences, Novo Nordisk, GlaxoSmithKline, Altimmune, Bausch Health, and others. 

Khalili reports relevant disclosures with Gilead, GSK, Resolution, and Intercept.

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Jophlin LL, Singal AK, Bataller R, et al. ACG clinical guideline: alcohol-associated liver disease. 

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McKnight-Eily LR, Okoro CA, Mejia R, et al. Screening for alcohol use and brief counseling of adults—13 states and the District of Columbia, 2017. 

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Dietary Guidelines for Americans, 2025–2030

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National Institute on Alcohol Abuse and Alcoholism. Alcohol treatment in the United States. Updated March 2026. Accessed October 2, 2026.

Lieber SR, Jones AR, Jiang Y, et al. Pharmacotherapy for alcohol use disorder is underutilized among commercially insured adults with alcohol-associated liver disease. 

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Articles

US alcohol consumption has begun declining post-pandemic, yet heavy drinking continues rising in adults aged 50–64, positioning ALD burden to keep increasing due to exposure–disease lag and worsening metabolic comorbidity. Clinicians are encountering more women, more metabolic risk, and later-stage presentations (cirrhosis rather than steatosis). Missed or delayed diagnosis remains common in primary care, underscoring the need for routine alcohol screening and early fibrosis assessment. Integrating AUD treatment—including harm-reduction approaches, telehealth stepped care, and pharmacotherapy—remains a major unmet opportunity.

Drinking fell for the first time since COVID-19, but not for adults 50 to 64. Hepatologists explain what clinicians can do to close the gap.

The Liver Keeps the Score: Americans Are Drinking Less, but Alcohol-Associated Liver Disease May Lag

Baseline motivation to reduce drinking, measured separately as patients' self-rated importance of cutting back and their confidence in being able to do so, was significantly associated with better outcomes among patients with 

and unhealthy alcohol use, independent of treatment assignment, according to a randomized controlled trial of a telehealth-delivered stepped alcohol treatment (SAT) model.

The trial missed its primary endpoint — so why did researchers still call it a success? See the

 on drinking reduction, abstinence rates, and how SAT stacked up against usual care.

Higher baseline confidence predicted a 43% increase in the odds of achieving less-than-moderate alcohol use, the trial's primary endpoint (Odds Ratio [OR] 1.43 per point), while higher baseline importance predicted a 40% increase in the odds of 30-day abstinence at 6 months (OR 1.40 per point). Notably, patients assigned to SAT, which centers on motivational interviewing, also saw significantly greater reductions in weekly drinking compared with those receiving usual care. 

Baseline Motivation Predicts Alcohol Reduction in Chronic Liver Disease

"One of the strongest predictors we found for successful alcohol reduction was patients' baseline motivation, and also their confidence and emphasis on the importance of reducing alcohol use," said senior author Mandana Khalili, MD, Chief of Clinical Hepatology and Director of Clinical and Translational Research in Hepatology at Zuckerberg San Francisco General Hospital, and Professor of Medicine at UCSF, in an interview with HCPLive. "This to me highlights that motivation is not just a patient characteristic. It's really something that clinicians can actively help strengthen."

How Motivational Interviewing Is Used to Treat Alcohol Use in Liver Disease

In the SAT model, motivational interviewing took the form of 3 telehealth sessions over 6 weeks, including an initial 45-minute visit followed by 2 20-minute follow-ups, conducted by clinical psychologists familiar with the effects of alcohol on liver disease.

"It's built around helping patients explore the reasons for change," said Khalili. "That is beyond just letting them know that it's important to stop drinking."

While hepatology visits tend to emphasize protecting liver health, she noted that patients often raise other motivations just as readily, such as improving their sleep, their mood, their relationships with family, their finances, or simply feeling healthier overall.

"Helping patients connect alcohol reduction with the goals that are personally meaningful to them increases their motivation," she said, "and it's much more effective in sustaining behavioral change."

Why the Model Was Designed to Step Up, Not Just Start There

That same logic extended to how the trial structured escalation of care. Patients who did not reduce their drinking after the initial motivational interviewing sessions were referred to addiction medicine specialists for more intensive treatment, including pharmacotherapy.

"The advantage of the step care model is that it's designed to meet patients where they're at," she said.

Patients with less severe alcohol use, she explained, may respond to motivational interviewing alone, while those with more severe alcohol use disorder, or who don't respond initially, can step up to more intensive services.

Sex Differences in Alcohol Reduction Outcomes

The study also noted that the reduction in drinks per week associated with SAT was significantly greater among women than men (interaction estimate −0.94; 

= .046). When asked, Khalili was quick to caveat the finding.

"This study was not designed necessarily or powered to look at subgroup analysis, so we have to be cautious about that," she said. "We also saw that women benefited strongly, and this sort of raises a hypothesis that potentially integrating alcohol [treatment] into the hepatology setting can also be beneficial to them and reduce some of those barriers."

Delivering the Model in a Safety-Net Setting

Khalili also pointed to where the trial was conducted as part of its significance. Of the 3 participating sites, 2 were Veterans Affairs medical centers and 1, Zuckerberg San Francisco General Hospital, is a safety-net hospital serving a population with comparatively fewer resources.

"This may be not as much in a Veterans Affairs healthcare system, they have additional resources accessible to them, but in particular in safety-net settings, it's quite challenging," she said.

She called the fact that the model could be delivered successfully in that setting "a testament to the fact that we could potentially replicate these models in other healthcare settings."

Can Hepatologists Deliver Motivational Interviewing Without Addiction Specialists?

That question of replication, Khalili said, comes down largely to workforce, not infrastructure. Most hepatology clinics don't have behavioral health specialists on staff, but she argued that shouldn't be a barrier to adopting a model like SAT.

"Motivational interviewing is a skill that can be taught to hepatologists and other members of a healthcare team," she said, adding that wider telehealth adoption has made delivery logistically feasible even in systems that previously lacked access to this kind of integrated care. Close coordination with addiction medicine specialists remains essential for the smaller subset of patients who need to step up to more intensive treatment.

Editor’s Note: Khalili reports relevant disclosures with Gilead, GSK, Resolution, and Intercept.

A randomized controlled trial of stepped treatment to reduce unhealthy alcohol use in patients with chronic liver disease.

 Published online June 24, 2026. doi:10.1097/HEP.0000000000001796.

Yes, telemedicine can reduce alcohol use for liver disease patients.

Videos

Mandana Khalili, MD, discusses how baseline motivation predicted alcohol reduction in a stepped treatment trial for liver disease patients.

A telehealth-delivered stepped alcohol treatment (SAT) model was associated with greater reductions in weekly alcohol consumption among patients with 

 and unhealthy alcohol use compared with usual care, according to findings from a randomized controlled trial. 

Although SAT did not significantly improve the trial’s primary endpoint of achieving less-than-moderate alcohol use at 3 and 6 months, participants receiving SAT had significantly greater reductions in mean drinks per week at both time points after adjustment for study site and baseline characteristics.

Telehealth Stepped Alcohol Care Reduced Drinking in Liver Disease

The study highlights a persistent challenge in hepatology, where unhealthy alcohol use is common among patients with CLD, and guidelines recommend integrating evidence-based alcohol treatment into liver care despite limited availability of these services in routine clinical practice.

“We wanted to really test a practical, scalable model that could be incorporated into routine hepatology practice and adapted for patients that may have changing needs over time,” senior author Mandana Khalili, MD, told 

How the Telehealth Alcohol Treatment Trial Was Designed

Investigators enrolled 157 adults with CLD and unhealthy alcohol use across 3 hepatology clinics in Northern California, including Zuckerberg San Francisco General Hospital and 2 Veterans Affairs health systems. These participants were randomly assigned to receive SAT (n = 81) or usual care (n = 76) and were followed for 6 months.

The cohort had a median age of 61 years, 86% were male, 48% had cirrhosis, and 78% met criteria for alcohol use disorder. Mean alcohol consumption at baseline was approximately 32 drinks per week.

SAT consisted of up to 3 telehealth motivational interviewing sessions delivered over 6 weeks. Participants who continued unhealthy alcohol use at 3 months were stepped up to addiction medicine services, including structured counseling and pharmacotherapy when appropriate.

The investigators designed the model as a practical and scalable approach that could be incorporated into routine hepatology practice and adjusted based on patients’ changing treatment needs. Usual care consisted of routine alcohol screening and brief provider counseling.

The primary endpoint was the proportion of participants reporting less-than-moderate alcohol use at 3 and 6 months. Secondary outcomes included mean drinks per week, 30-day abstinence, and heavy episodic drinking.

Telehealth Alcohol Treatment Reduced Weekly Drinking but Missed Primary Endpoint

The trial did not meet its primary endpoint. At 6 months, 56% of participants receiving SAT and 53% receiving usual care reported less-than-moderate alcohol use, a nonsignificant difference.

However, after adjustment for study site and baseline characteristics, participants assigned to SAT experienced significantly greater reductions in mean drinks per week compared with usual care at both 3 and 6 months.

“One of the most important findings was that the participants receiving the step care treatment had a significantly higher reduction in the amount of average alcohol intake that they had per week,” Khalili said.

30-day abstinence at 6 months occurred in 29% of participants receiving SAT compared with 18% of those receiving usual care, although the difference did not reach statistical significance. Investigators also observed a trend toward less heavy episodic drinking with SAT.

Alcohol consumption declined in both groups over time. Khalili noted this likely reflects the impact of ongoing hepatology care itself but said the structured intervention produced an additional reduction in alcohol use beyond usual care.

The reduction in drinks per week appeared greater among women. Independent of treatment assignment, Latino participants and those with higher baseline motivation to reduce alcohol use were more likely to achieve the primary endpoint.

Among participants reporting 30-day abstinence, alcohol biomarkers confirmed abstinence in nearly 70% of those tested. Follow-up remained high, with completion rates of 90% at three months and 89% at six months. Rates of hospitalization, death, new cirrhosis, and hepatic decompensation did not differ significantly between groups.

Clinical Pearl: Why Harm Reduction Matters in Chronic Liver Disease

Although the trial did not achieve its primary endpoint, the reduction in weekly alcohol consumption may still be clinically meaningful for patients with chronic liver disease, explains Khalili.

Continued alcohol use can contribute to liver disease progression and negatively affect quality of life and mental health. For patients who are not immediately able to achieve abstinence, reducing alcohol consumption may represent an important treatment goal while they engage with behavioral interventions, addiction medicine, and pharmacotherapy.

“Even reducing alcohol consumption short of complete abstinence is meaningful clinically in this population with chronic liver disease and is also consistent with a model of harm reduction,” Khalili said.

How Telehealth Alcohol Treatment Could Expand Hepatology Care

Current liver disease guidelines recommend alcohol screening, behavioral counseling, pharmacotherapy when appropriate, and referral to addiction services. However, integrated alcohol treatment remains uncommon in hepatology clinics.

Khalili said the findings support integrating alcohol treatment directly into hepatology practices rather than relying exclusively on specialty addiction referrals.

“Rather than thinking of alcohol treatment as something that happens only in specialty addiction services, hepatology clinics themselves can play an active role in engaging patients in this type of evidence-based care,” she said.

The stepped-care model allows treatment intensity to increase according to patient needs, beginning with motivational interviewing and escalating to addiction medicine services and medication management when appropriate.

Investigators also found strong patient engagement with the approach. Despite enrolling patients from safety-net and Veterans Affairs health systems, populations that may experience socioeconomic barriers, mental health challenges, and difficulty accessing care, follow-up rates were approximately 90% at both three and six months.

“This lets us know that chronic liver disease patients are receptive to discussing alcohol use and engaging in treatment if it’s offered in patient-centered and accessible ways,” Khalili said.

Editor’s Note: Khalili reports relevant disclosures with Gilead, GSK, Resolution, and Intercept. 

Telehealth stepped alcohol treatment reduced weekly drinking, but not the primary endpoint, among patients with chronic liver disease.