The CAGE assessment is a screening tool that can help individuals and clinicians identify issues with alcohol or drug use behaviors. It can be used in any clinical setting and can quickly highlight substance use issues. However, it is not a diagnostic tool and should only be used as an initial screening, followed by further diagnostic investigation.
- CAGE is a questionnaire that can be used to detect alcohol and drug use issues.
- CAGE can be used in any setting, including when taking a patient’s history during any mental or physical health assessment, and can highlight drug and alcohol issues that require intervention.
- CAGE is quick and easy to use and can often accurately identify severe drug and alcohol use issues, but does not clarify in-depth details such as frequency or amount of use.
The CAGE questionnaire and screening for alcohol and drug abuse risk
The CAGE questionnaire is a standard screening tool consisting of four questions and is used to identify alcohol and drug use dependency and problem behaviors. The acronym stands for Cut, Annoyed, Guilty, and Eye, which are keywords in each of the four questions. [1]
The questionnaire asks about cutting down on drinking, becoming annoyed at others’ criticism of drinking, feeling guilty about drinking, and the need to use alcohol as an eye-opener in the morning.
CAGE was initially developed by Dr. John A. Ewing, an addiction therapy clinician, professor of psychiatry, and founding director of Bowles Center for Alcohol Studies, and first published in 1984. [1] Ewing created the questionnaire to screen for alcohol use issues and it has since been adapted to include drug use within the four questions (CAGE-AID). [2]
CAGE is a widely used screening tool, particularly in primary care, as it is quick to administer, taking less than a minute, and is effective at identifying people with alcohol or drug dependency and addiction. [3][4]
How to administer the CAGE assessment
The CAGE assessment can be asked in any clinical setting, including inpatient hospital, psychiatric care, primary care, or emergency departments. It can be administered to anyone who consumes any amount of alcohol. It can be used as part of history-taking when assessing an individual for mental or physical health concerns. [3]
Additionally, as it is a simple and quick tool, people can utilize the CAGE assessment at home without a professional, to identify issues with their own or others’ alcohol use behaviors.
Limitations and considerations
Research shows that CAGE is effective at identifying severe alcohol use issues but is less effective at recognizing less severe alcohol use. More detailed screening tools may be needed in these cases. [4][5]
Additionally, as there are only four questions, results can only provide an indication of alcohol use issues. For example, two out of four positive answers can be enough to suspect an alcohol use issue but do not provide a clear answer as to the frequency or amount of alcohol use.
The final question, the ‘eye-opener’, is deemed by some clinicians to be a clear indication of problem drinking, regardless of whether the other questions are answered positively. [3]
CAGE vs. Other screening tools
CAGE can be a helpful tool to identify severe and unhealthy alcohol use but cannot determine specifics such as frequency or amount of use and the impact of alcohol on functioning. Other more descriptive screening tools can be helpful in ascertaining more in-depth information such as the Alcohol Use Disorders Identification Test (AUDIT) and Michigan Alcoholism Screening Test (MAST). [4][5]
However, CAGE can be a beneficial tool to highlight potential alcohol use issues that may otherwise be overlooked. For example, some people may under exaggerate their alcohol use or may not mention alcohol consumption during screening for other health issues. CAGE can be a quick tool for clinicians to assess high-risk people. [5]
CAGE and CAGE-AID: Self-test option
The CAGE and CAGE-AID self-tests are quick, four-question screening tools designed to help individuals recognize potential alcohol or drug use issues. The CAGE-AID version expands the original CAGE questionnaire to include drug use, making it more comprehensive for identifying substance-related concerns.
CAGE
- 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?
- Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?
CAGE Adapted to Include Drug Use (CAGE-AID)
- Have you ever felt you ought to cut down on your drinking or drug use?
- Have people annoyed you by criticizing your drinking or drug use?
- Have you felt bad or guilty about your drinking or drug use?
- Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?
Scoring and interpretation
Each question scores 0 for No and 1 for Yes. A score of two or more indicates alcohol use issues, with higher scores suggesting more severe drinking behaviors.
Some clinicians argue that a score of 1 or more can highlight problem drinkers, particularly if the final question is answered positively. Needing alcohol or drugs first thing in the morning may suggest that the individual experiences withdrawal, indicating an addiction or dependence. [2][3]
What to do after taking the CAGE questionnaire
People who answer yes to one or more of the CAGE questions may require professional assessment and support. It may be beneficial after answering these questions at home to share the answers with a healthcare professional, who can provide advice and referrals to appropriate services if required. If the questionnaire is asked in a clinical setting, it is likely that a referral will be made at this time.
An addiction specialist will likely ask further questions to gather more information about the individual’s alcohol use and may advise entering a treatment program to manage use.
People who do not drink or use drugs regularly and answer no to all questions need not take any action following these questions. Also, CAGE might be a helpful tool for people to recognize issues in their alcohol or drug use that they want to manage without professional help.
Treatment options for substance abuse
People with identified alcohol or drug use issues can utilize professional treatment to reduce or stop drinking or drug use. This can include:
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