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What is the CAGE Questionnaire?

CAGE is an acronym that refers to a series of questions that medical professionals may use to screen patients for alcohol misuse. The questionnaire may also be self-administered.

Dr. John Ewing developed the CAGE questionnaire in 1984 as a simple tool to identify alcohol dependence.9 

There are four questions in the CAGE questionnaire:9

  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 get rid of a hangover (eye-opener)?”

You can access the CAGE questionnaire online here.

The CAGE questionnaire is similar to the Alcohol Use Disorders Identification Test (AUDIT) and the Fast Alcohol Screening Test (FAST). In fact, it’s one of several hundred screening measures out there.

Other types of tests include calculating the “mean corpuscular volume” of a patient’s red blood cells and determining their “liver transaminase levels” and “gamma-glutamyl transpeptidase level.”2

How Does the CAGE Assessment Screen for Alcohol Misuse?

The CAGE assessment is easy. The widely validated screening technique asks open-ended questions that dive into a person’s drinking habits and behaviors. 

It also delves into how someone feels about their own alcohol consumption, as well as how they feel about people’s opinions about it. All of these questions can give insights into whether or not a drinking problem is possible.

It is important to recognize that the CAGE questionnaire was designed and intended to be a method of screening for alcohol misuse. It is not a diagnostic instrument. It does not collect any information about the quantity of alcoholic beverages consumed, the frequency of alcohol consumption, or the pattern of drinking.5

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What Questions Does CAGE Ask?

CAGE stands for cut, annoyed, guilty, and eye-opener:9

  • The CAGE questionnaire asks about a patient’s attempts to “cut” down on drinking (C).
  • It asks about whether or not they are “annoyed” by people’s concerns surrounding their drinking habits and behaviors (A).
  • It asks if they ever feel “guilty” for their drinking habit or how their behaviors while drinking impact those around them (G).
  • Lastly, it asks if they ever find themselves needing an “eye-opener,” or more alcohol, in the morning to curb a hangover or face the day ahead (E).

Note that healthcare professionals should not precede the CAGE questionnaire with any other questions regarding alcohol intake. Any inquiries about drinking quantity or frequency can significantly reduce the sensitivity of CAGE questions

Kicking off the conversation with the open-ended nature of these questions is key.6

However, after completion, the CAGE questionnaire may be followed up with more questions about alcohol usage and consumption rates.

How is the CAGE Screening Tool Scored?

The CAGE questionnaire scoring is simple.

Each question is given a 1 if the patient answers “yes” and a 0 if the patient answers “no.9 

The more “yes” responses (and, as such, the higher the score), the more likely it is that the patient has an alcohol problem. 

If the patient answers at least half of the questions with a “yes” to earn a total score of 2 or more, this is considered “clinically significant.”4

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How Effective is the CAGE Questionnaire?

Unfortunately, the CAGE questionnaire is largely underused, and people with alcohol problems are regularly undiagnosed and untreated. For example, only 30 percent of primary care physicians report regularly screening their patients for substance use. And, of them, only about half (55 percent) report using the CAGE assessment.5 

However, the CAGE questionnaire is largely considered an effective assessment of alcohol misuse

CAGE measures for sensitivity and specificity. Sensitivity means that people with alcohol dependence will test positive for it. Specificity refers to the percentage of true negatives, which means that people who do not have an alcohol dependence will test negative.

CAGE shows 91 percent sensitivity for alcohol dependence and 87.5 percent for alcohol misuse. It also shows 87.8 percent specificity for alcohol dependence and 80.9 percent for alcohol misuse.1

Because the CAGE questionnaire is just four questions, it’s a quick and easy assessment. In fact, it’s one of the most efficient ways to detect excessive drinking and for identifying alcoholism.5

Answering the CAGE questionnaire can be a positive step in the right direction for people with alcohol problems if and when it’s used correctly.

What are the Limitations of the CAGE Assessment?

The CAGE assessment does have some limitations. For example, it does not take gender, race, and cultural differences into account when assessing consequences or perceptions of problem drinking.8

Also, the CAGE questionnaire does not distinguish between a person’s current drinking problems and past drinking problems. For example, asking someone if they have ever felt guilty about drinking does not specify when that was and whether or not they still do.3

Lastly, the CAGE questions do suffice in assessing the extent of the drinking problem, if one is detected.3

Similarly, the CAGE questionnaire is not a valid assessment of substance misuse. However, CAGE-AID is a variation of the CAGE questionnaire that substitutes “drink” with “drink or drugs” in each question.

Resources

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A;, do Amaral RA;Malbergier. “Effectiveness of the CAGE Questionnaire, Gamma-Glutamyltransferase and Mean CORPUSCULAR Volume of Red Blood Cells as Markers for Alcohol-Related Problems in the Workplace.” Addictive Behaviors, U.S. National Library of Medicine.

Bush B;Shaw S;Cleary P;Delbanco TL;Aronson MD; “Screening for Alcohol Abuse Using the CAGE Questionnaire.” The American Journal of Medicine, U.S. National Library of Medicine.

Cage Questionnaire.” CAGE Questionnaire - an Overview | ScienceDirect Topics.

CAGE Substance Abuse Screening Too.” Johns Hopkins.

Charles P. O’Brien, MD. “The Cage Questionnaire for Detection of Alcoholism.” JAMA, JAMA Network, 5 Nov. 2008.

H;, Steinweg DL;Worth. “Alcoholism: The Keys to the Cage.” The American Journal of Medicine, U.S. National Library of Medicine. 

NIAAA Publications.” National Institute on Alcohol Abuse and Alcoholism, U.S. Department of Health and Human Services.

Volk, R J, et al. “Item Bias in the Cage Screening Test for Alcohol Use Disorders.” Journal of General Internal Medicine, Blackwell Science Inc, Dec. 1997.

Williams, Nerys. “Cage Questionnaire.” OUP Academic, Oxford University Press, 18 Aug. 2014.

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