CAGE Alcohol Abuse Questionnaire, Screening & Assessment

What is the CAGE Questionnaire?

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

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

• Cut
• Annoyed
• Guilty
• Eye-opener

These refer to the four questions on the CAGE questionnaire:

• 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 in the morning to steady your nerves or get rid of a hangover? (eye-opener)

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How is the CAGE Screening Tool Scored?

The CAGE questionnaire scoring is simple. Each question scores a 1 if the person answers yes, and a 0 if the person answers no.⁹

The more yes responses (and, as such, the higher the score), the more likely the person has an alcohol problem. If the person has a total score of 2 or more, this is considered clinically significant.⁴

How to Use CAGE Assessment Results

After completing the CAGE assessment, you should discuss your results with your doctor. They may follow up with more questions about your alcohol usage and consumption rates.

If they determine you have an alcohol use disorder, they can ensure you get the best treatment options. Your doctor can refer you to a specialist for further evaluation and diagnosis.

If they do so, ask what kind of treatment they recommend. You may consider seeking a therapist who specializes in treating addictions.

Support groups are also available for those struggling with addiction. These groups provide support and information on how to cope with addiction. They often include 12-step programs like Alcoholics Anonymous (AA). 

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Cage-AID and Other Screening Tests

Additional screening tests are available to identify people at risk for developing alcoholism or other substance abuse problems. Doctors use some of these tests to diagnose different medical conditions. 

CAGE Adapted to Include Drugs (CAGE-AID)

The CAGE-AID questionnaire is the most similar to the CAGE test. It adapts the questionnaire to screen for drug use alongside alcohol use.

The questions in a CAGE-AID test are:

• Have you ever felt you should reduce your drinking or drug use?
• Have people annoyed you by criticizing your drinking or drug use?
• Have you ever 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?

Michigan Alcohol Screening Test (MAST)

The Michigan Alcohol Screening Test (MAST)  has more than 20 binary (yes/no) questions that screen people for alcohol dependence. It's a comprehensive questionnaire that includes questions like:

• Have you ever lost a job because of drinking?
• Can you stop drinking without difficulty after one or two drinks?

The questionnaire aims to assess the following:⁹

• An individual's self-appraisal of their perceived control over drinking behavior
• Alcohol-related personal and interpersonal problems
• Symptoms indicative of more severe alcohol dependence 

Alcohol Use Disorders Identification Test (AUDIT)

The AUDIT test contains 10 multiple-choice questions to measure:

• Alcohol intake
• Potential dependence on alcohol
• Experience of alcohol-related harm¹⁰

The AUDIT score ranges from 0 to 40. A score of 15 or more indicates the likelihood of alcohol dependence and more significant alcohol-related problems.

Alcohol Use Disorders Identification Test-Concise (AUDIT-C)

AUDIT-C is similar to the full AUDIT test, but it only takes 3 minutes to complete. A score of 4 for men and a score of 3 for women can raise suspicion of alcohol use disorder.

The AUDIT-C consists of three questions:

• How often do you have a drink containing alcohol?
• How many standard drinks containing alcohol do you have on a typical day?
• How often do you have six or more drinks on one occasion?

Tolerance, Worried, Eye-Opener, Amnesia, K/Cut-Down (TWEAK)

The TWEAK test is for pregnant women's risk drinking behavior. The test measures tolerance, worry, eye-opener, amnesia, and k/cut down.

Those with a higher score indicate a tendency towards risky drinking behaviors. Reducing alcohol intake during pregnancy and postpartum follow-ups will help prevent future alcohol-related fetal damage.¹¹

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How Does the CAGE Assessment Work?

The CAGE Assessment is a widely validated screening technique. The open-ended questions give insights into whether or not a person could have a drinking problem.

The CAGE questionnaire is a screening method for alcohol misuse. It's not a diagnostic instrument.

Moreover, any inquiries about drinking frequency can significantly reduce the effectiveness of the questions. For instance, the questionnaire doesn't consider that some people drink in social situations and others don't.

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

How Effective is the CAGE Questionnaire?

Unfortunately, the CAGE questionnaire is vastly underused. 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 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, meaning people who don't have alcohol dependence will test negative

Statistics for CAGE show: 

• 91 percent sensitivity rate for alcohol dependence 
• 87.5 percent for alcohol misuse
• 87.8 percent specificity for alcohol dependence
• 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 alcoholism.⁵

Limitations of the CAGE Assessment

The CAGE assessment does have some limitations. For example, it doesn’t consider gender, race, and cultural differences when assessing the consequences or perceptions of problem drinking.⁶

The questions are also inadequate in assessing the extent of the drinking problem if one is detected.³ The 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. It can help determine if alcohol addiction treatment is necessary.