CAGE: Alcohol Use Disorder Screening

The CAGE questionnaire is a 4-item yes/no screening questionnaire for alcohol use disorder, named for its four questions: Cut down, Annoyed, Guilty and Eye-opener ^[1]. Each "yes" scores 1 point, and 2 or more is the usual positive screen.

What does the CAGE measure?

The CAGE is one of the most widely used screening questionnaires for alcohol use disorders. It was developed by Dr. John Ewing, who described how the four questions were identified, and how they were used in clinical and research studies, in JAMA in 1984 ^[1].

The CAGE is brief and easy to give. It is best at detecting alcohol abuse and dependence, and it is not an appropriate screen for less severe forms of drinking ^[2].

It serves as an initial screen to identify clients who need a fuller substance use assessment, such as the AUDIT for alcohol or the DAST-10 for drugs.

Screening, not diagnosis

The CAGE is a screening tool. A diagnosis of alcohol use disorder requires a full clinical evaluation by a qualified professional, including detailed history, physical examination, and application of DSM-5-TR criteria.

Copyright and permissions

The CAGE was developed by Dr. John Ewing, founding director of the Bowles Center for Alcohol Studies at the University of North Carolina at Chapel Hill. The Center states that clinicians and researchers publishing studies with the CAGE should cite Ewing (1984) and that no other permission is necessary, unless it is used in a profit-making endeavour, in which case the Center requires a negotiated payment.

How do you give the CAGE?

The CAGE can be used either way: it is often administered verbally by a clinician during a routine interview, but it also performs well as a brief self-report questionnaire. The four yes/no items take under one minute to complete in either format.

The four CAGE questions

1. Cut down. Have you ever felt you should cut down on your drinking?
2. Annoyed. Have people annoyed you by criticizing your drinking?
3. Guilty. Have you ever felt bad or guilty about your drinking?
4. Eye-opener. Have you ever had a drink first thing in the morning (eye-opener) to steady your nerves or get rid of a hangover?

Administration best practices

• Frame as part of routine health screening to reduce defensiveness
• Ask about lifetime patterns ("Have you ever"), not just current use
• Positive screen requires detailed follow-up assessment (AUDIT, clinical interview)
• Consider AUDIT-C or AUDIT for more sensitive early-stage detection

How do you score and interpret the CAGE?

Each "yes" scores 1 point, for a total of 0–4. A score of 2 or more is the most widely used cutoff for a positive screen, indicating likely alcohol use disorder and the need for further clinical evaluation.

A score of 0–1 is considered a negative screen: no strong indicators of problematic alcohol use were detected, and routine health promotion is appropriate.

When the CAGE is positive (2 or more)

• Give the AUDIT (10 items) for a detailed assessment
• Conduct a clinical interview (quantity, frequency, consequences)
• Assess for co-occurring mental health conditions (PHQ-9, GAD-7)
• Provide a brief intervention or refer to an addiction specialist

Psychometric properties

A review of 3 reliability and 16 validity studies ^[2]:

• Reliability. Test-retest reliability was high (0.80–0.95), with adequate correlations (0.48–0.70) with other screening questionnaires ^[2].
• Validity. The CAGE was valid for detecting alcohol abuse and dependence in medical and surgical inpatients, medical outpatients and psychiatric inpatients, with an average sensitivity of 0.71 and specificity of 0.90 ^[2].
• Primary care. Performance in primary care has been varied ^[2].

A lower cutoff can work in some settings. In 1,667 male veterans at a walk-in triage clinic, one or more "yes" responses achieved 86% sensitivity and 93% specificity against a DSM-III-R diagnostic interview ^[3].

Limitations

• Screening, not diagnosis. A positive screen should be followed by a proper diagnostic evaluation using standard clinical criteria ^[2].
• Less severe drinking. The CAGE is not an appropriate screen for less severe forms of drinking ^[2]; the AUDIT or AUDIT-C is the usual choice for earlier detection.
• Variable performance by population. Performance in primary care has been varied, and the CAGE has not performed well in white women, prenatal women, and college students ^[2].
• Lifetime framing. Items ask "Have you ever", so a positive screen may reflect past rather than current drinking.
• Alcohol only. The CAGE does not screen for drug use; pair it with the DAST-10 or use the ASSIST or CAGE-AID.

CAGE vs other substance use screening tools

CAGE vs AUDIT

The CAGE's main advantage is brevity. Its questions focus on dependence features (guilt, criticism, morning drinking), so it misses less severe drinking ^[2]. The AUDIT also covers hazardous drinking patterns, which makes it the better choice for prevention-focused care.

CAGE vs DAST-10

The CAGE and the DAST-10 screen for different substances, so they are complementary, not alternatives: the CAGE covers alcohol and the DAST-10 covers prescription and illicit drugs.

• Use both where substance use is common (pain clinics, emergency departments, mental health settings), or use a single tool that covers all substances, such as the ASSIST.
• A negative CAGE does not rule out a drug problem.

CAGE vs SBIRT

The CAGE is a screening tool: it identifies problems but does not address them. SBIRT (Screening, Brief Intervention and Referral to Treatment) is a full protocol that screens, gives a brief intervention and connects clients to treatment; the CAGE can be its screening step, though the AUDIT is more often used.

Documenting CAGE scores

CAGE scores belong in the Objective section of a SOAP note.