CAGE: Alcohol Use Disorder Screening

The CAGE questionnaire is a 4-item screening tool for identifying alcohol use disorders. Fast, validated, and easy to administer in any clinical setting.

What is the CAGE Questionnaire?

The CAGE questionnaire is one of the most widely used screening tools for identifying alcohol use disorders. Developed in 1974 by Dr. John Ewing, CAGE is an acronym for the four questions: Cut down, Annoyed, Guilty, Eye-opener.

Each question is answered yes or no, with each "yes" response scoring 1 point. The CAGE is brief (under 1 minute), easy to administer, and has high specificity (93% in hospital-based studies; 77–90% in primary care) for detecting alcohol dependence. It's particularly effective for identifying chronic alcohol use issues rather than binge drinking or early-stage problematic use.

The CAGE is validated for use in primary care, emergency departments, mental health settings, and substance use treatment programs. It serves as an initial screen to identify patients who need more full substance use assessment (e.g., AUDIT, DAST-10).

Screening Tool, Not Diagnostic

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

Public Domain

The CAGE questionnaire is in the public domain and free to use in clinical and research settings. No licensing fees or permissions are required.

The Four CAGE Questions

Have you ever felt you should cut down on your drinking?

Have people annoyed you by criticizing your drinking?

Have you ever felt bad or guilty about your drinking?

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

Negative Screen Low Concern Positive Screen Strong Positive High Concern

Score of 0–1 is considered a negative screen. No strong indicators of problematic alcohol use detected. Routine health promotion is appropriate.

CAGE Scoring & Interpretation

Sensitivity & Specificity

CAGE performance characteristics:

• Specificity: 77–93% (93% in hospital/inpatient settings; 77–90% in primary care)
• Sensitivity: 60-95% (varies by population, cutoff ≥2)
• Best for detecting chronic alcohol dependence
• Less sensitive for early-stage problematic use or binge drinking

When CAGE is Positive (≥2)

Follow-up actions for positive screens:

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

Important Limitation

The CAGE is less effective for detecting early-stage problematic drinking or binge drinking patterns. Consider using AUDIT or AUDIT-C for more sensitive early detection, especially in college students or younger populations.

CAGE vs Other Substance Use Screening Tools

Understanding the differences between substance use screening tools helps you choose the right assessment for your clinical setting and patient population.

CAGE vs AUDIT: Ultra-Brief vs Detailed Alcohol Screening

Clinical Guidance: The CAGE's brevity is its only advantage, it takes 30 seconds but misses early-stage problem drinking that the AUDIT detects. CAGE focuses on late-stage dependence symptoms (guilt, criticism, morning drinking), which means it identifies patients only after alcohol problems are severe. The AUDIT is the superior choice for prevention-focused care, it catches hazardous drinking patterns before full dependence develops. Reserve CAGE for crisis settings where even 2 minutes is too long (busy ERs), but use AUDIT everywhere else.

When CAGE is acceptable: Emergency department rapid triage, crisis intervention settings, when literally only 30 seconds available. Otherwise, invest the extra 90 seconds for AUDIT, the superior sensitivity to early intervention opportunities is worth it.

CAGE vs DAST-10: Alcohol-Only vs Detailed Drug Screening

Clinical Guidance: CAGE and DAST-10 assess different substances, they're complementary, not alternatives. CAGE screens for alcohol problems; DAST-10 screens for drug problems (prescription and illicit). In settings where substance use is common (pain clinics, emergency departments, mental health settings), use both or use a combined tool like ASSIST (Alcohol, Smoking, and Substance Involvement Screening Test) that covers all substances. Don't assume someone with negative CAGE has no substance issues, they could have significant drug problems that CAGE doesn't detect.

platform: Many clinics use CAGE for alcohol + DAST-10 for drugs as a rapid combined screening battery (total time: 3-4 minutes). This catches polysubstance use patterns that single-substance tools miss. Alternative: use ASSIST (8 minutes) for full single-tool assessment of alcohol, tobacco, cannabis, cocaine, amphetamines, opioids, and sedatives.

CAGE vs SBIRT: Screening Tool vs Clinical Protocol

Clinical Guidance: CAGE is just a screening tool, it identifies problems but doesn't address them. SBIRT is a complete evidence-based protocol that screens, intervenes, and connects patients to treatment. Think of CAGE as one possible screening component (though AUDIT is preferred in SBIRT protocols). Modern best practice: implement full SBIRT protocols in primary care, emergency departments, and integrated care settings. Screening without intervention misses the opportunity to change behavior, SBIRT's brief intervention alone reduces risky drinking by 20-30% in primary care populations.

Implementation tip: If you're only using CAGE for screening without follow-up intervention or referral, you're missing most of the clinical benefit. Consider implementing full SBIRT: screen with AUDIT (not CAGE), provide brief intervention for moderate-risk patients, refer high-risk patients to specialty treatment. SBIRT is reimbursable under many insurance plans, making it financially sustainable.

Documenting CAGE scores in clinical notes?

CAGE scores belong in the Objective section of your note. See our SOAP notes guide and Intake Notes guide for templates and examples.