How should I administer and interpret the CAGE questionnaire for alcohol use screening?

CAGE Questionnaire Administration and Interpretation

The CAGE questionnaire should be administered as four simple yes/no questions, with a score of 2 or more positive responses indicating clinically significant alcohol-related problems and warranting further evaluation for alcohol use disorder. 1, 2

The Four CAGE Questions

Ask the patient these exact questions, scoring each as 0 (no) or 1 (yes):

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

1, 2

Scoring and Interpretation

• Score 0-1: Negative screen - alcohol use disorder unlikely
• Score ≥2: Positive screen - clinically significant alcohol problems present, requires further assessment 1, 2

Performance characteristics: The CAGE demonstrates 71% sensitivity and 90% specificity using the ≥2 cutoff, with likelihood ratios increasing dramatically with higher scores (LR for score of 2 = 4.5; score of 3 = 13; score of 4 = 100) 1, 3

Administration Method

The CAGE can be administered either:

• Orally during clinical interview - no difference in accuracy compared to written format 4
• Written self-administered questionnaire - equally valid 4
• With or without introduction - asking an open-ended question first ("What do you drink during the day?") does not improve detection rates 4

The questionnaire takes less than 1 minute to complete and requires no special training 1.

Important Limitations and Caveats

The CAGE has significant weaknesses you must understand:

• Focuses on lifetime consequences rather than current drinking patterns or quantity consumed 1
• Poor sensitivity for risky/hazardous drinking - only 14-39% sensitive in older adults and 38-49% in pregnant women 5
• Better at detecting dependence than abuse - sensitivity is 84% for alcohol dependence but only 61% for alcohol abuse 6
• The "E" (eye-opener) question is the most discriminating item, with sensitivity of only 18% for abuse but 46% for dependence 6

When CAGE is Positive (Score ≥2)

Immediate next steps:

1. Quantify actual alcohol consumption - the CAGE doesn't tell you how much the patient drinks 1
2. Consider administering AUDIT (10-item questionnaire) for comprehensive assessment of drinking patterns, dependence symptoms, and alcohol-related problems in the past year 1, 7
3. Evaluate for alcohol use disorder using DSM-5 criteria (≥2 of 11 criteria in 12 months indicates AUD) 2
4. Screen for medical complications - check for liver disease, trauma history, falls, fractures, emergency department visits 1

Alternative Screening Approach

For better detection of risky drinking (not just dependence): Consider using AUDIT or single-question screening instead, particularly in:

• Women
• Older adults (>60 years)
• Pregnant women
• Patients where you need to assess current drinking quantity

The single question "How many times in the past year have you had 5 or more drinks (4 for women) in a day?" has 82-87% sensitivity and 61-79% specificity for the full spectrum of alcohol misuse 5.

Clinical Context

The CAGE remains widely used because:

• Extremely brief (4 questions)
• Easy to memorize
• No scoring complexity
• Can be incorporated into routine history
• Familiar to most physicians 1

However, recognize that it was designed for hospitalized inpatients with established alcohol problems 1, making it better suited for detecting severe alcohol use disorders than for general screening of risky drinking in primary care populations.