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 the CAGE measures

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.

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 to administer 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

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

CAGE scoring and interpretation

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.

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.

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

Psychometric properties

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

Reliability and validity

A review of 3 reliability and 16 validity studies (Dhalla & Kopec, 2007) found high test-retest reliability (0.80–0.95) and adequate correlations (0.48–0.70) with other screening tools. The CAGE was valid for detecting alcohol abuse and dependence in medical and surgical inpatients, ambulatory medical patients and psychiatric inpatients, with an average sensitivity of 0.71 and specificity of 0.90. In 1,667 male veterans at a walk-in triage clinic, a cutoff of one or more "yes" responses achieved 86% sensitivity and 93% specificity against a DSM-III-R diagnostic interview (Liskow et al., 1995).

Limitations

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.

• Screening, not diagnosis. A positive screen should be followed by a proper diagnostic evaluation using standard clinical criteria.
• Variable performance by population. Performance in primary care patients has been varied, and the CAGE has not performed well in white women, prenatal women, and college students (Dhalla & Kopec, 2007).
• 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

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.