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

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 alcohol-associated liver disease (ALD) 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.

Part 1 of this series traced how ALD climbed for 25 years, spiked during the pandemic, 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 alcohol use disorder (AUD), not just the liver.

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 even as drinking fell overall.¹

"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 interview with HCPLive.

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

Binge drinking 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 MASH patients."

"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 Hepatology 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 interview with HCPLive. "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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