Cage Screening Instrument

The CAGE Questionnaire is the most commonly used screening instrument for alcohol use disorders. The CAGE was designed to quickly screen adults for drinking problems by asking them four questions about their drinking experiences across their lifetime. The questions were selected because they appeared to be sensitive indicators of covert problem drinking in preliminary studies. Each of the questions has within it a key word that serves to form the CAGE acronym.

The four key CAGE questions are as follows: (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)?

Individuals complete the CAGE on their own in a written format or the questions may be asked as part of an interview. Individuals answer the questions either yes or no. Each yes response to a CAGE question is scored as 1. A total score of 0 to 4 results from summing positive answers. A score of 2 or higher is considered clinically significant and raises concern that an individual may have problematic alcohol use patterns or symptoms of alcoholism. The CAGE takes less than 1 minute to complete and score. No special training is required to use the CAGE, and it may be used without permission. The CAGE has been translated into multiple languages other than English, including Flemish, French, Hebrew, Japanese, Polish, Portuguese, and Spanish.

When used in the context of a clinical interview, affirmative answers to CAGE questions may be explored by professionals with additional questions to understand the nature and severity of the patients' potential drinking problems. For patients who report they have tried to cut down their drinking, professionals might ask about the difficulty of this process, how successful they had been in reducing or stopping drinking, and when prior elevated drinking levels resumed. Patients who note annoyance about criticism of their drinking could be asked about the sources and nature of the criticisms and how the criticisms have affected their self-perception. Professionals might ask patients who have indicated feeling guilty about their drinking to describe what caused the guilt, how drinking affects their behavior, and what impact the guilt has had on their current intentions to drink. Finally, with patients who report having had morning eye-openers, professionals could explore the types of alcohol withdrawal symptoms they may have experienced, the recency of the symptoms, and how often they may have been drinking throughout the day.

The extent to which the CAGE items yield consistent responses (i.e., that it is reliable as a measure) has not received much research attention. In a study of underage drinkers treated in emergency departments, however, the CAGE item responses typically varied by differences in respondents' drinking experiences rather than problems in item interpretation or other errors. Moreover, the CAGE has been included in numerous studies with large sample sizes of patients seeking treatment in general medical or psychiatric settings to determine how well it screens for problematic drinking. In general, a cutoff score of 1 or 2 has been found to improve the accuracy of clinicians in identifying patients who have and do not have drinking problems (as determined by independent clinical or structured diagnostic assessments). Studies that compare the CAGE with single items such as "How much do you drink?" or to biological measures such as liver function tests or breath tests for alcohol show the CAGE greatly improves the ability of clinicians to accurately screen patients for alcohol use disorders.

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