← Thriving with Addiction with Dr. Jonathan Avery
Thriving with Addiction with Dr. Jonathan Avery
July 4th Alcohol Series: The Latest Science and Changing Attitudes with Dr. Mashal Khan
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A
Welcome to the Thriving with Addiction podcast, where we explore how recovery is not just about surviving, but about truly living. Each week, we'll dive into the science stories and strategies that help people and families heal from addiction and build healthier, more resilient lives. I'm your host, Dr. John Avery.
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B
Let's get started.
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C
I'm John Avery, and welcome back to Thriving with Addiction. Today I'm joined by Mashal Khan. Mashal is an assistant professor of clinical psychiatry at Weill Cornell Medicine and associate program director for the Addiction Psychiatry Fellowship. As a psychiatrist on the liver transplant team here, he evaluates organ recipients and donors and provides them with transitionary care. His area of interest and clinical focus include technology assisted interventions for substance use disorders and the management of alcohol use disorder in patients with alcohol liver disease. And he's written and edited several great books on these topics as well. He's also a trusted colleague and friend here at Cornell. Masha, welcome.
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B
Thank you. Thank you for having me. This is very exciting.
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C
Now tell me a little bit about your journey to become this expert in alcohol use disorder that you are. How did you get here?
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B
Oh, it's. It's been a long journey, John. I'd say a combination of life experiences and clinical exposure led me down this path. You know, generally, I'd say the path to addiction psychiatry was, was more obviated by my exposure to, you know, during residency years when, as you're treating mental health disorders, you recognize, and very quickly that, you know, people tend to try to self medicate or they have certain relationships with different kinds of substances that either perpetuate or exacerbate their mental health disorders. So that put me on a path of wanting to learn more about treating substance use disorders. And with time, I recognized how gratifying the work with that patient population was. And it's just snowballed from there on. And, you know, you've played a significant role in helping me, you know, find this niche. And we've done some work together in writing a few books and putting some educational content out, but now we have this very wonderful clinic which is an integrated clinic that serves this population of people that have alcohol use disorder with any form of liver disease. And we're very proud of it. And there are a few of them in the city, in the, in the country and in the city that are doing some great work. So very pleased to be part of that as well.
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C
We're very lucky you chose to specialize in that because, you know, among all the substances, alcohol is still the number one thing we Treat as addiction professionals. And we need great folks like you specializing it. And I always like to ask, because my journey was notable for people telling me not to go into addiction. What stigma did you experience along the way? Did family, friends agree with your decision to become an addiction psychiatrist? What have you noticed through this process of becoming an expert?
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B
Yeah, I'd say from the start I didn't really have the best support in pursuing psychiatry because being South Asian background, we have very. Not to play into caricatures, but we, we, you know, family and friends, we have a different sort of expectation around what you would do with having a medical degree. Become a cardiologist or a surgeon or something like that. So when I chose psychiatry, you know, it did raise a few eye clouds.
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C
I can hear the collective groans. Yes.
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B
But yeah, over time, everybody understood the need for it. The stigma towards mental health and substance use disorder, I think, is a very universal thing and it's a bit more palpable in the developing world. There's a lot of taboo. People don't seek help as much. They often resort to other, you know, religious counseling or something like that, as, as a, as a, as a means of addressing their issues. But I think with the world being as interconnected as it has been over the past 26 years, that that need has been better recognized over time and people have better insight around, you know, seeking treatment and the need for providers. And so, yeah, I now find family members and friends being a bit more proud of my choices.
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C
That's good. Well, let's hop into our main topic today, which is, which is alcohol. What's, what's the latest on how people are, are drinking these days to give us an update.
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B
So the good news is that it's. There's less, less use of alcohol overall in the population. I think Gallup came out with its consumption habits survey last year saying that I believe 2025. In 2025, there was the least amount of consumption of alcohol reported by individuals in comparison to the highest amount of consumption, which was around 2023. 62% of individuals endorsed consuming alcohol, and that has slowly declined since then. So it went to, I think, 58% in 2024 and then dropped to 54% last year. And a lot has shifted, I think just because of the odd awareness that people have around the impacts of alcohol and potentially having witnessed the, the exacerbation of alcohol, their unhealthy relationship with alcohol during the pandemic years may have played a role. We're seeing Gen Z and the, the generations younger from the, from them being a bit more mindful of their alcohol consumption, gravitating towards other healthier choices. And other than that, you also see how the Surgeon General came out in 2025 and made this causal association of how alcohol contributes to different cancers and recommended revision of guidelines around alcohol consumption and reinforce the need for better screening and treatment recommendation resources. And beyond that, I think there's also overall, in America, there is now, I believe around 53% of Americans believe that even moderate drinking is considered harmful. So that's a significant shift. Something that was to me a bit unexpected, but a welcome change.
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C
I know it's striking and especially the younger generations and the ability for folks to be just sort of casually sober, it's no longer a stigma to not drink. You can sort of tell folks, hey, I'm being healthy, I'm taking a month off or I don't drink just for health reasons. And it's, that's a real big change. It felt harder to say no before for some reason. Yeah.
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B
And you, you also hear about things like sober October and dry January and there, there are these new trends. I don't know if we, we can say that Joe Rogan starts sober October or where this dry jacket he starts over October. I, I, I heard from someone that, you know, his podcast following, you know, started the sober October thing at some point.
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C
Let's claim another month on this podcast. Let's pick a, pick a third one. Yeah, but it's good the, no, the numbers are going down and part of that, to your point, is the risk that even the recognition that even mild drinking can lead to harms.
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B
The research that we have available shows us that and it's different for men and women. So beyond a drink in women, you start seeing some bodily effects that are considered liver injury and other bodily effects that are considered harmful. And for men it's around two drinks or more. And you know, the, the survey that came out from SAMHSA, the Alcohol Taken Health study that SAMHSA posted in 2025, also sort of pointed out that any amount of alcohol consumption would result in increased risk, health risks.
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C
When does it, you're sort of alluding to it. When does it become sort of alcohol addiction or alcohol use disorder? You mentioned some of the risk factors, maybe having a family history or history of other substance use, mental health, trauma. Tell us some of those risk factors and when it becomes addiction.
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B
Yeah. We clinically define alcohol use disorder or alcohol addiction as through a different lens. Right. We have a 12 point criteria that needs and you need to meet at least two of those criteria over a period of 12 months. But you know, those 12 points are broken down into categories of impaired control, impacts in social functioning, risky use, and then there's also the element of tolerance of withdrawal. But I would say the risk factors that contribute to developing a use disorder often are things like, you know, it could be, you know, being in an adverse environment, whether it's, you know, being in having financial difficulties or like a stressful environment in general. Typically we see that men are twice as more likely to develop a use disorder in comparison to women that that gap is now narrowing just because of shifts in use trends. Also, women tend to have a tendency of what we call have experiencing this telescoping effect even though they start later in life. But they can sort of have a more expeditious development of use disorder if they're using the same amount or heavy amounts. Patterns of drinking are important if one tends to gravitate towards heavier consumption, which is defined once again differently for men and women. For men it's around, I think, five drinks per day or more. And for women it's three to four standard drinks a day or more. And the more prolonged that use pattern is, the more likely it is to develop a use disorder. Then you know, the genetic piece, it's not like if you have a family member that has alcohol use disorder that you're going to seek out alcohol and become addicted to it. It's more about having how your body processes the alcohol and then how does your brain respond to the alcohol. So genetics can actually be also protective. So I have this one deficiency in an enzyme that protects me from developing a use disorder because whenever I drink alcohol I get very sick, I get very nauseous. So it's sort of like this aversive experience and so I don't indulge. But for some people, the opposite is true. They metabolize much faster. So for them drinking more is required to achieve the same intoxication effect as they witness amongst their peers. And then at the level of the brain, there are things like certain receptor differences where you could have a very euphoric response to drinking. And so this is this subset in the population that reports feeling very warm and fuzzy and you know, elated in response to drinking. So as you can imagine, if you're having a down day and you drink a beer or two and that makes you feel warm and elated, then that's just a, that just, you know, plugs you into this self medication pathway where you're likely to self medicate your, your way into forming a use disorder.
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C
And I like that you highlighted the, the heavy consumption patterns because I think people sometimes think when you have alcohol use disorder, alcohol addiction, you're drinking every day. But I think we're recognizing that that heavy consumption or binge drinking is one can cause you to have an alcohol use disorder where it's really impacting your function, brain and body. And people often say I only drink twice a week, but sometimes that can be enough to really get you into trouble.
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B
Yeah, yeah, for sure. Yeah. Alcohol use disorder comes in all different shapes and forms. Right. They're the daily low level drinkers that concretely ra remove themselves from it and they need it to function and maybe go to sleep or to unwind. And without it there would be an anxious mess that might meet the criteria for a mild use disorder, perhaps, but we would recognize at that. And then there are those individuals that have to drink like eight to 10 drinks because that's the way that they've always been done it since they were in their college years and they don't know any other way and they haven't slowed down. And now that they're in their late 20s, early 30s, 40s, whatever you want to, whatever it is, they, they continue to drink at that pattern and, but they're seeing more consequences emerge from it. Whether, whether it's like consequences at home, at work, while being on the road and trying to drive with, you know, a high blood alcohol content and getting into trouble there. There's so many impacts in different shapes and forms that alcohol use disorder presents
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C
itself and it's often co occurring with mental health or other substance use disorders.
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B
Yeah, yeah. The, the statistic we often talk about is that, you know, mental health, having a mental health use disorder, a messi adult having a mental health disorder puts you at risk of three times more likely of risk of developing a use disorder. And having a use disorder makes it three times more likely of you developing a mental health issue with alcohol. We see that, you know, in the short term people find relief from low mood or anxiety or something like that from, but over time they end up developing, you know, depression or anxiety as a consequence of the, of their continuous alcohol use.
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C
And then when you have the severe alcohol use disorder, we talked about some of the mild impacts on the body, but severe alcohol use, it does really impact the liver hijack the reward pathway.
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B
Yeah.
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C
When it's a severe condition, what do we notice about what it does to the body overall?
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B
You know, I'd say zooming out For a second before we talk about severe use disorder. As soon as alcohol enters your body, it, you know, it's an irritant. So it irritates your esophagus, it irritates your stomach, makes you more prone to gastritis, makes your GERD worse, makes, you know, more prone to ulcers. And then it causes, you know, as it moves through the gut, it causes a shift in your microbiome and causes hormones, unhealthy biome to sort of flourish, which we call dysbiosis. And that dysbiosis, that unhealthy biome then causes gut leakage and, you know, allows certain toxins to pass through. Now these toxins, along with the alcohol as well, are going to the, to the liver next to get processed. They damage the liver there. The alcohol itself, as it's broken down that one of its metabolites, the acetaldehyde, causes damage to the liver, but it doesn't stop there. It also causes these oxidative stress and reactive oxidative species to cause more damage. Our immune system comes in, views that as an attack and then sends in more attack vectors onto it and then causes more damage on top of that. The lucky. You know, the good thing about the liver is that's the only organ in the body that has the capacity to heal itself. But it can only do so if the inciting event or the thing that's causing the damage can back off for long enough. So people that have this moderate, severe use disorder, they tend to have higher levels of consumption. And, you know, the, the insult to the liver can, is quite persistent, so the liver doesn't have a chance to heal itself. And that's what results in some cell death and fibrosis. And over time that fibrosis accumulates and develop, one can develop cirrhosis. But as you know, the alcohol, alcohol sort of affects all organs in the body, right? So adjacent to the liver, you have your pancreas. It causes damage to, that can cause early onset diabetes, causes acute pancreatitis, chronic pancreatitis. And then, you know, at the heart, it can cause increased risk of cardiovascular disease, arrhythmias. At the level of the brain, you've experienced disinhibition, impact on motor control, motor coordination. And with prolonged use, you have like, development of memory issues, you have like, increased risk of strokes, other issues that emerge. And then, you know, as the surgeon General pointed out last year to the nation that it also increases the risk of developing various cancers all across the body. And they identified seven major different organ cancers and. But the others are also suspected.
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C
So if someone hears all that and they says, oof, I need to scale back even before we think about treatment, how does one decide on trying for moderation versus abstinence? I guess it might vary based on the severity of one's alcohol use disorder. But what, do you counsel patients around that? Because I imagine a lot of people come to you and they're like, all right, I hear I'm. It's hurting my body, but can I just drink less to start? What do you recommend?
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B
Yeah, I mean, we always meet people where they're at. We never, you know, push for one thing or the other. I do point out to people that have severe use disorders that sometimes moderation without a gap of abstinence may be more difficult and challenging for them to achieve. And often that is the case. It's very difficult to dial down from drinking 10 drinks per sitting to drinking what we consider to be a conservative moderation use is less than three drinks for women, less than four drinks for men. Through the moderation management criteria, the organization, not the consensus we have as a community, but the organization, but the National Institute of Alcohol Abuse and Alcoholism, the NIAAA defines moderation management as being limited to less than a drink for women, less than two drinks for men, which is significantly hard for people that are going from that heavy consumption use down to that. But we have tools that can help them. Naltrexone is my favorite tool for that. Topiramate is also great. And GLP1s that now that are emerging as, you know, this new drug that we was a bit of a happy surprise for everyone in the field can also serve in that capacity. But I. To answer your original question, I think it's. It's a thing that requires individual assessment and then guidance with a healthcare provider on the path. Cutting down too drastically can bring its own risks. So if someone's consuming 10 to 12 drinks a day or sitting and they shifted down to two drinks, they put themselves at risk for severe restlessness, tremors, um, you know, other consequences like seizures and tremors, delirium tremens, or alcohol hallucinosis. Those are. Some of them are medical emergencies, and we, we want to avoid them.
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C
That's a good point that we didn't mention in terms of the impact on the body that when you're drinking a lot, you can end up with a withdrawal state that can be deadly and you sometimes need medication assistance to. To get to. To zero and then to. To tackle treatment.
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Yeah, And.
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And then when we want to tackle treatment, there's luckily good treatments and more treatments than ever. You mentioned some of them there. Maybe let's start with the oldest and one that we know. 12 step work or Alcoholics Anonymous. Who's that for? What do you recommend these days?
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B
Yeah, I'm a big fan of the 12 step interventions or the 12 step phenomenons such as Alcohol Anonymous, Alcoholics Anonymous or child step facilitation. They're great. Alcoholics Anonymous has a bit of a spiritual bend to it that can be at times a deal breaker for some individuals, but over time. But overall what we see is that, you know, it helps individuals develop insight, take accountability. They connect with peers that have gone through similar, a similar process. That community can really help them work through the process of, you know, having accountability, making amends and just working through a process that allows you to sort of reconcile the damage that has occurred both internally and externally in your life. And it's such a niche experience to have alcohol use disorder for some people that it requires having that community to relate to it because people around you sometimes don't understand it or don't understand why you keep on engaging in this very problematic use despite all these consequences. So for that reason alone I, I, you know, I find alcohol, Alcoholics Anonymous or other trust facilitation groups to be really nice and I recommend it to everyone to try it out. And if that's not for them, then we send them to, you know, either Smart recovery or if you know what we've been hearing some great feedback on is women for sobriety as well. It's been a great intervention for many women that have come to our clinic and they've reviewed it really well.
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C
Right. Luckily there's increasingly amount of online and in person groups that are 12 step alternatives. But I always recommend to your point that they try a few 12 step because it is the biggest and it does really resonate for people even when they don't think intuitively it will. It can be a real game changer. But luckily there's other groups and then there's other psychosocial treatments like therapies. Tell us a little bit about those.
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B
Yeah, I view those psychosocial interventions or therapies as a three step flow process where you break it down to step one is engagement in which you have your motivational interviewing and motivational enhancement techniques and even things like sbirt, what was it? Survey brief intervention and recommendation retrievement. That's what it stands for. And then step two is skill building in which you have Things like CBT relapse prevention and DBT mindfulness. And then step three is sustainment in which you have things like peer supports, AA smart recovery, women for recovery and family involvement through CRAFT and other things, and contingency management, things like that. Those fall into. And so another way of thinking about these treatments is motivation ignites change, skill guides change, reinforcement sustains change, and then community protects change.
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C
And so if someone's struggling and they're thinking about, do I go first to a group or a therapist, what do you recommend? Like what's. When you raise your hand and say I'm in trouble, how do you decide where to go first then?
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B
Ideal scenario. That would be depending on your stage or willing, you know, where you are in your stage of change. If you have decided that you need to make a change, then you know, seek out, go attend a group, go attend an AA meeting and see, you know, attend a few of them. And. But, but you do need to have the right tools, right? So nowadays you have so many. It's not like the old days where you had to go to a trained CBT therapist and you had to sit down with them to develop those skills. You have these technology assisted interventions nowadays where you have these apps, these chatbots that can help you through developing different skills. So I just, I. One of my patients is in this sort of field and they develop, they have a use disorder and recently they used Claude to vibe code, you know, a CBT app for them or um, and also an accountability app for them to track how much they're consuming and you know, when their triggers come up and things like that. So we're in a very different era than we. Than what we were in 10 years ago. And you know, resources, if they're unavailable to you, they can be self generated at this point, which is wild to think about. It's like we're literally living in the future now. I feel like we're part of the Jetsons or something. But.
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C
And you edited a nice book on technology assisted interventions for alcohol use disorder. And I guess you're sort of describing what Holly Whitaker said in our very first episode, which is start anywhere. Like if it's technology, if it's a tech, it's an app that resonates. Go there. If it's a group, go there, find a therapist to help build skills. Just. Yeah, just get started. Because there's more good treatments and more accessible treatments than ever.
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B
Yeah, 100%.
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C
And then some people benefit from meds. Tell us the latest on you mentioned some of them Already. But the latest on medications for alcohol use disorder.
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B
Yeah, the conventional medications we have are the FDA approved medications. Right. So you have disulfiram or ant abuse, which basically is part of an aversion therapy. It protects you from drinking by, you know, causing these side effects which makes you get sick if you drink, essentially. So you avoid drinking as a consequence because you're afraid of the consequences. Right.
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C
And if anyone hasn't listened to the Dave Koechner episode, he talks about Anabuse being the. After trying so many different things, including rehab, Anabuse was the thing that solidified recovery for him.
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Yeah.
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And big proponent of AA as well. So, yeah, he captured that effect quite well in that interview with you. And then there's naltrexone. I think you guys also talked about naltrexone in the same podcast where it basically, Naltrexone helps us by reducing cravings, but also helps us reduce the amount of consumption by taking away, by blocking the reward pathway and reducing the reward associated with drinking. So oftentimes what we'd observe is that people one or two drinks into it would be like, why am I drinking? It's not giving me the same feeling. And they would question whether or not they should continue to drink. And the good thing about naltrexone is you don't need to take it every day. You could also utilize it through the Sinclair method, which is just take it on the day that you expect to be drinking a few hours before and it would have a similar. The same effect. And the other conventional medication we have is a Camprosafe or Camprole, which essentially, you know, alleviates cravings associated with alcohol. Oftentimes the people places things in situations that we associate with alcohol use, service triggers that provoke cravings in us or and you know, cravings that we. We talk about it differently clinically. It's a spectrum which can be just the thought of drinking, that nostalgia of drinking or that visceral feeling of drinking or wanting to drink. And it helps with all of the above probably for some people. So these were the FDA approved medications that we all prescribe. And then those are. There are several non FDA approved medications that we use off label such as Topiramate, Topamax, which basically helps with cravings as well Gabapentin, which is one of my favorite non FDA approved meds which helps with both as it can help as for detoxing of when people have mild to moderate use disorder and they want to detox outpatient also helps maintain this or Address this imbalance that is created over time with consistent alcohol use where our body starts generating this more activating neurotransmitter to counterbalance the effects of alcohol and its sort of relaxing effects. And gabapentin therapy with gabapentin for the two to three month protocol that we all sort of subscribe to is helps sort of rebalance that seesaw a bit. Then there are other medications, but the one that's really popular nowadays is semaglutglutide, the GLP1, which is indirectly showing effects on alcohol cravings and reduces as showing reduction in alcohol use and on the fringes. But things that I'm more excited for is the psychedelic interventions that are still being heavily deeper researched. There's a lot of data associated with psychedelics such as psilocybin, ketamine and there is nmdma. But you know, a lot of those are still unavailable to us as therapeutics still being researched and whatnot. So over. I'm, I'm sure that in due time we'll have some therapeutics available to us to help our patient population. Right.
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C
And hopefully we're at the point where, I mean there might be some stigma and lack of knowledge, but if someone's out there and they're struggling with drinking and they want to consider meds that an internist could potentially prescribe these, a psychiatrist could. And then to your telehealth interventions again, there are sort of telehealth platforms as well that you can sort of in a discreet way like people get Viagra, you can get meds for alcohol use disorder mailed. Mailed to you, which I think is sort of a cool new thing.
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B
Yeah, yeah, there's that. There's also other, you know, tech assisted interventions like soberlink, a great device that helps build accountability.
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C
I thought of a Breathalyzer that emails the results to everybody.
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B
Yeah, it has that facial recognition tool as well that really makes sure that it's you that's breathing in and not your dog or something like that.
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C
Right. So luckily there's, there's great outpatient options. The therapies, the groups, the medications. When do you consider inpatient for somebody? I guess one is inpatient for detox if they need that. Withdrawal management that can be deadly. When do you send people to inpatient for rehab?
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B
It really depends on what the individual's needs are. And they're not always that you have a severe use disorder. And now you need to go into a monitor setting so that we can both safely detox you and then keep you In a, in an environment that is observed and offer you, you know, therapies and interventions that can then equip you to deal with the world that was triggering or, you know, made you more prone to use. But you know, sometimes has to do with, you know, understanding what a rehab would serve in this person's treatment journey is do they need a break from those people, places, things and situations that even though they go through like an outpatient detox, sort of pull them back into using again and again. And by giving them that break, you then instill them with those resources and the skills that allow them to sort of better counter those triggers and you give them enough of a break that their brain sort of becomes a bit more equipped and capable of like saying no because, you know, early on into your recovery, you're a bit more impulsive and compulsive and just returning to use. So there's that. And also, you know, if the rehab is doing their job well, they, they're also connecting you to an intensive outpatient program right after that maintains the, the, your learning journey and continues to help you work on the skills you had developed in rehab and over time helps you to form a community around a community and supports around your recovery.
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C
Yeah, and the nice thing in my mind about the inpatient and outpatient rehabs is they have everything we were talking about all in one spot. They have the groups, they have the therapies that do the CBT, DBT, they can prescribe the medications. They also have 12 step groups right there. And so it's, it's a one stop shop for early recovery and sometimes that makes it easy. And then they set you up with those resources when you leave. So it can be a helpful introduction, although a scary introduction at times to treatment. And then let's not forget about the family. Addiction doesn't happen in isolation and drinking really can impact the family across generations. What supports do you recommend for families as they see a loved one going through this?
- [37:54]
B
Yeah, the, you know, there are, there are different approaches, but essentially Al Anon is my go to the first thing I recommend to families that are being impacted. Al Anon is great. It has family groups that essentially help you understand where you know what your role is. And it helps you sort of understand, you know, differences between enablement and, you know, the different interpersonal elements that contribute to their use. Or also there are things like smart recovery, family and friends, parents of addicted loved ones, families anonymous community and craft. You know, CRAFT is great. CRAFTS stands for community reinforcement and family training.
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C
So a therapist led intervention for families.
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B
That's a therapist led intervention indeed. And that helps with the more. Treatment resistant family treatment or avoidant addicted individuals that have had difficulties engaging and family members that have certain dynamics in place that may be also serving as barriers. So it helps refresh and see things through a more therapeutic lens that would be more conducive towards getting them better.
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C
I'm so lucky to count you as a friend and colleague and your expertise in alcohol use disorder is so appreciated. I appreciate you coming on today.
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B
Likewise, we're all very lucky to have you as leading our addictions department and also being such a leader in the field, addressing stigma for many years and spreading the good word on Narcan. And you've inspired multiple generations of people to take on addictions training, which is also amazing because there's a huge need for addiction trained professionals in the field. So thank you. And now thank you for doing this podcast or starting this podcast because it's going to spread the good word even further.
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C
Thank you. And I couldn't do it without you and so grateful for our collaborations through all these years. So thanks again for coming on today.
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A
Thanks for listening to the Thriving With Addiction podcast. If you found today's episode helpful, please follow and subscribe wherever you listen to your podcasts and share it with someone who might benefit. You can also connect with me on Instagram, LinkedIn and YouTube, or visit thrivingwithaddiction.com to learn more. Stay tuned for next week's episode and remember, thriving is possible.