CAGE Questionnaire Alcohol Screening

CAGE Alcoholism Assessment

The CAGE alcoholism assessment is a brief, quick to administer, non-confrontational questionnaire for screening of alcohol use, problem drinking and alcoholism.

It is widely used in primary care and general health settings as an initial screening tool and so is not population specific (designed for use in adult and adolescents over 16 years), but rather meant to flag those who drink excessively and may require specialized support and treatment.

The National Institute of Alcohol Abuse and Alcoholism recommends that all patients who declare that drink alcohol should be screened with CAGE. Some particularly at-risk populations may include pregnant women where drinking can have disastrous effects, college students, and DUI and domestic violence offenders.

The CAGE questionnaire was first introduced in 1968 by Dr. John Ewing at North Carolina Memorial Hospital and was developed to facilitate the quick detection of drinking patterns in patients. The tool was then published in 1984, in an article which elaborated on the design of the CAGE questions (following a study on 130 randomly selected patients) and their successive use in clinical studies.

The name CAGE comes from the acronym: Cut down on drinking, Annoyed by criticizing drinking, Guilty about drinking and Eye-opener that can help clinicians remember the key aspects of the questions.

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

*Some sources deem a positive answer to question 4 as highly concerning for unhealthy drinking behavior, even with negative answers to all other three questions.

Responses to the CAGE questionnaire are scored 0 for “no” and 1 for “yes.

CAGE Interpretation and Next Steps

A cut off of 2 points was established as clinically significant and indication the patient screens positive and so, should be subject to further review. Scores of 2 points or more were found to have 93% sensitivity & 76% specificity for the identification of excessive drinking and a 91% sensitivity & 77% specificity for the identification of alcoholism.

The higher the score, the greater the likelihood that the interviewee might have face problems controlling alcohol consumption.

Please note that, as CAGE is a screening tool, high scores mean the patient test positive and suspicions are raised but this is not a diagnostic tool.

If it is suspected that the patient is minimizing their alcohol use, qualitative questions can be employed to further investigate the nature and extent of the alcohol problem.

Validation and Limitations

Bernadt et al. published a comparison between the CAGE, the brief MAST and Reich rapid alcohol use tools and eight laboratory tests, in order to evaluate their ability to detect excessive drinking and alcoholism in 385 psychiatric patients.

CAGE was effective in identifying 9 out of 10 alcoholics and 93% of excessive drinkers, compared to only 33% detected by the laboratory tests.

The questionnaire has since been extensively validated (including via receive operating characteristic analysis for problem drinking behaviours) and is currently considered an excellent screening tool with high levels of sensitivity and specificity.

There are several modified versions available, to facilitate use in screening for other substance use disorders, such as the CAGE-AID questionnaire, adapted to include drug use.

As the CAGE is essentially a self-report questionnaire and as drinking behavior may be regarded as a sensible and stigmatized subject, results may be altered by social desirability bias. Completing the questionnaire at a distance, for example online, may increase the accuracy and honesty of responses, as opposed to a face-to-face administration of the questionnaire.

Other Alcoholism Screening and Diagnosis Tools

It is important to remember that the CAGE tool is a screening not a diagnosis instrument and where patients screen positive, further investigations will be required. A similar tool is the FAST hazardous drinking assessment that also consists of 4 screening questions.

Tools such as the MAST or AUDIT test are able to obtain more information and are more sensitive to drinking behaviour aspects and signs of hazardous and harmful drinking:

The Michigan alcohol screening test (MAST) consists of 24 “yes” or “no” questions and can be self-administered. The questions are constructed in such way to allow not only an evaluation of the subject but also to allow the subject to visualize the extent in which their alcohol use impacts on lifestyle, social and family situations.

The AUDIT-C (Alcohol Use Disorders Identification Test) is one of the most popular alcohol screening methods. It consists of 10 questions, the first three focusing on alcohol consumption, questions 4 to 6 address alcohol dependence whilst the last four questions focus on alcohol related problems.

References

Original reference

Ewing JA. Detecting alcoholism: The CAGE questionnaire. JAMA: Journal of the American Medical Association. 1984; 252, 1905–1907.

Validation

Mayfield D, McLeod G, Hall P. The CAGE questionnaire: Validation of a new alcoholism instrument. American Journal of Psychiatry. 1974; 131, 11 21-1123.

Bernadt MW, Mumford J, Taylor C, Smith B, Murray RM. Comparison of questionnaire and laboratory tests in the detection of excessive drinking and alcoholism. Lancet. 1982; 1(8267):325-8.

Other references

Aertgeerts B, Buntinx F, Fevery J. Ansoms S. Is there a difference between CAGE interviews and written CAGE interviews. Alcoholism: Clinical and Experimental Research. 2000; 24(5), 733-736.

Fiellin DA, Reid MC, O’Connor PG. Screening for alcohol problems in primary care: Systemic review. Journal of General Internal Medicine. 2000; 15(Suppl. 1), 65-66.

Reynaud M, Schwan R, Loiseaux-Meunier MN, Albuisson E, Deteix P. Patients admitted to emergency services for drunkenness: Moderate alcohol users or harmful drinkers? American Journal of Psychiatry. 2001; 158(1), 96-99.