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    CAGE Questions for Alcohol Use

    Screens for excessive drinking and alcoholism.
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    • CAGE should be included among standard history questions in primary care, emergency department, psychiatric and inpatient hospital settings.
    • The recommendation of the National Institute of Alcohol Abuse and Alcoholism is that all patients who drink alcohol should be screened with the CAGE questions. (Fiellin DA 2000)
    • CAGE is designed for adults and adolescents >16 years.
    • Other at-risk populations where CAGE or another alcohol screening assessment is indicated include:
      • Pregnant women
      • College students
      • Arrested and incarcerated persons, especially DWI and domestic violence offenders
    • The CAGE questions are 4 simple and easy-to-remember to screen for alcohol use problems.
    • The scale can be administered in < 1 minute by clinicians.
    • CAGE is a screening tool: screening measures are NOT intended to provide a diagnosis; diagnosis occurs if/when a patient screens positive.
    • An abnormal or positive screening result may thus “raise suspicion” about the presence of an alcohol use problem, while a normal or negative result should suggest a low probability of an alcohol use problem.
      • Scores of 2 or more are a typical cut-off as “screening positive,” as studies show >90% sensitivity for diagnoses of alcohol disorders (excessive drinking, alcoholism).
    • Physicians often overlook alcohol problems in patients. (Kitchens JM 1994)
    • Simply asking patients how much they drink often leads to an estimate lower than the actual number of alcoholic drinks per day.
    • Alcohol disorders are treatable despite physician bias otherwise. (Kitchens JM 1994)
    • Without identification and treatment, alcohol problems lead to significant morbidity and mortality:
      • Alcohol is a major factor in suicides, homicides, violent crimes, and fatal motor vehicle accidents. Nearly 88,000 people die from alcohol-related causes annually, making it the third leading preventable cause of death in the United States. (Centers for Disease Control and Prevention 2014)
      • Alcohol is primarily or secondarily implicated in a large number of medical problems.
      • The mortality rate in those who drink six or more drinks per day is 50% higher than the rate in matched controls. (Klatsky AL 1992)
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    Advice

    • If a clinician suspects that the patient is minimizing his or her alcohol use, more qualitative questions (i.e., about quantity, frequency, pattern of drinking) should be asked to better determine the nature and extent of the problem.
    • Other validated tests for further assessment include:
      • Michigan Alcoholism Screening Test (MAST)
      • Alcohol Use Disorders Identification Test (AUDIT)
    • Data shows that CAGE is less effective in recognizing less severe drinking disorders. In situations where time allows for more in-depth interviewing, incorporating the AUDIT may help to identify a wider spectrum of alcohol problems. (Fiellin DA 2000)

    Management

    When screening results are positive, the patient should be referred for further evaluation and treatment of an alcohol use problem. This will vary based on available resources, but ideally the patient will be sent to an addiction psychiatrist, psychologist, or addiction treatment program.

    Critical Actions

    In any hospital setting where access to alcohol may be limited, always monitor for signs/symptoms of alcohol withdrawal, even in patients who have not screened positive for an alcohol problem.

    About the Creator
    Dr. John A. Ewing
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