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

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.

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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.

Mandana Khalili, MD

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