CAGE Questionnaire for Alcohol Use
Popular among clinicians, the CAGE questionnaire is an alcohol assessment tool widely used as a screening test to check for problem drinking or alcohol dependency.
It’s a highly effective and straightforward questionnaire made up of four easy-to-answer questions.
Because the CAGE questionnaire is designed to be less conspicuous than simply asking someone if they have a drinking problem, any discussions about alcohol intake should be limited until after the questionnaire has taken place.
The test will be deemed less effective if these clinicians don’t stick to this rule.
In addition, rather than asking a patient outright if they have a drinking problem, an open-ended introduction to their potential problem is much more reliable. 
What are the CAGE Questions?
There are four straightforward and unobtrusive questions that doctors ask, which are:
- 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 get rid of a hangover (eye-opener)?
How and When Should the CAGE Questionnaire be Used?
Medical professionals should be using the CAGE questionnaire when alcohol use could be especially problematic or damaging.
Populations that are particularly at risk and in desperate need of alcohol assessment should also be considered a priority.
These people can include:
- College students
- Pregnant women
- Those who have been arrested or incarcerated
Settings where healthcare professionals often use the CAGE questionnaire during standard history questions include inpatient hospital settings, psychiatric units, primary care, and the emergency department.
Although individuals can use the Cage questionnaire, it was not created for self-diagnosis.
Instead, clinicians best use it in a primary care setting as an alcohol assessment tool when checking for possible alcohol abuse.
Although initially aimed at patients over 16 years of age, it’s commonly used for patients of any age who drink alcohol or may have a drinking problem, according to the National Institute of Alcohol Abuse and Alcoholism. 
Scoring the CAGE Assessment
The questionnaire is easy to answer and score. An answer of yes results in one positive score, meaning that the likelihood of alcohol dependency increases with each yes.
A score of two or three would indicate a clinically significant alcohol dependency or alcohol use disorder.
Although the average consensus for indicating problem drinking or alcoholism is a score of two, a score of one can also be used by primary care clinicians to identify more patients who may have an alcohol abuse disorder.
This recommendation comes from the Consensus Panel.
In addition, some of these questions may be given more priority by doctors. For example, the final question about drinking in the morning could be considered the most critical, as it can signify severe withdrawal symptoms. 
John A. Ewing, MD, (d. 2006), founding director of the Bowles Centre for Alcohol Studies at the University of North Carolina, developed the CAGE assessment in 1968.
Thus, Ewing was well equipped to create this study as an addiction therapy clinician and professor of Psychiatry Emeritus.
During the development of this questionnaire, 130 patients of a general hospital population were randomly selected to partake in an in-depth interview.
This led to the successful isolation of four questions that make up today’s CAGE questionnaire.
These questions could detect the sixteen alcoholics from the rest of the patients.
As an internationally applicable assessment instrument for identifying alcoholics, the CAGE questionnaire has been used ever since.
This continued use comes from its effectiveness in combatting the scarcity of alcohol assessment measures available for those with potential drinking behaviours.
How Reliable Is It?
Due to the robust cloud of stigma hovering over those who suffer from alcohol abuse, people can tend to lie or alter their answers as they may feel judged.
In addition, when people are asked directly if they have a drinking problem, it can make it difficult for doctors to ask effectively practical questions about a patient’s drinking habits.
However, the CAGE questionnaire and any related tests try to fix this by removing any potential for the patient’s perceived personal judgment.
Instead, asking straightforward, direct questions without any accusatory tones or judgements allows clinicians to receive more honest answers.
An excellent example of this is in the second question, which asks how other people perceive their drinking and doesn’t directly ask how drinking affects those around them.
During comparison research, it was found that scoring in this way resulted in a 93% sensitivity of accurately identifying alcohol dependency.
When comparing this with GGT liver function tests that detected only a third of patients drinking more than 16 drinks per day, the CAGE assessment proves to be highly efficient.
These results indicate that the CAGE questionnaire is a relatively accurate, quick, and easy way to screen patients for alcohol dependence which doesn’t cause undue upset or defensiveness. 
Variations on this Alcohol Assessment
Of course, the CAGE questionnaire isn’t the only test to check for alcohol or substance abuse. There are a few similar tests, with the most similar being the CAGE-AID questionnaire.
The addition of the word AID stands for ‘Adapted to Include Drugs’ and relates to how the questions are altered to check for substance abuse problems and include drug use terms.
The CAGE-AID questions are:
- 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)?
Other tests to check for alcohol use include:
- The Alcohol Use Disorders Identification TEST (AUDIT) is a more comprehensive screening tool recommended by the World Health Organization. This 10-question questionnaire allows for both potentially dangerous drinking habits and alcohol misuse to show themselves. 
- The Michigan Alcohol Screening Test (MAST) is amongst the oldest tests for alcohol use problems. It contains 24 questions directed towards both behaviour and negative consequences. Rather than looking at an individual’s current state, this test focuses more on their long-term history.
- TWEAK is a five-question test that looks for signs of alcohol abuse, such as high tolerance of alcohol use and blacking out. This test was initially developed to check for hazardous drinking habits in pregnant women with a focus on immediate care.
- Fast Alcohol Screening Test (FAST) is a test focussed on checking for drinking patterns that could increase a patient’s risk of psychological or physical complications. FAST is a four-question test that has been adapted from the AUDIT questionnaire.
While not a fail-proof test, it’s clear that the CAGE questionnaire is incredibly reliable in checking for signs of alcohol dependence due to the four unobtrusive and straightforward questions.
]This test works so well because it’s a speedy and dependable way to check for alcohol problems when time is of the essence and treatment is urgently needed.
Lastly, the fact that it avoids the potential for social stigmas surrounding alcohol users creates further opportunities for more honest answers.
- https://pubmed.ncbi.nlm.nih.gov/6471323/ ↑
- https://pubs.niaaa.nih.gov/publications/aa65/aa65.htm ↑
- https://www.ncbi.nlm.nih.gov/sites/books/NBK64830/ ↑
- https://pubmed.ncbi.nlm.nih.gov/6120322/ ↑
- http://apps.who.int/iris/bitstream/handle/10665/67205/WHO_MSD_MSB_01.6a.pdf;jsessionid=B7CE0721DCFEB2D7A02FB01C40D5BDAC?sequence=1 ↑