CAGE Questionnaire

The AUDIT (Alcohol Use Disorders Identification Test) is a 10-item questionnaire developed by the WHO that assesses three domains: hazardous alcohol consumption, dependence symptoms, and harmful consequences. Unlike the CAGE, it captures the full spectrum of problematic alcohol use including risky drinking that has not yet progressed to dependence.

The AUDIT-C is a shortened 3-item version focusing on consumption patterns (frequency, quantity, binge episodes). It is widely used in primary care because of its brevity and its ability to detect hazardous drinking in addition to dependence.

• Use the CAGE when you need a rapid verbal screen during a clinical interview, when the primary concern is alcohol dependence (rather than risky drinking), or when working in medical/surgical inpatient settings.
• Use the AUDIT or AUDIT-C in primary care for routine screening, when you need to detect the full spectrum of alcohol misuse (including hazardous and harmful drinking), in populations where the CAGE has reduced sensitivity (women, younger patients, ethnic minorities), or when a quantitative severity measure is needed.

Many guidelines, including those from the USPSTF and NICE, now recommend the AUDIT-C or full AUDIT over the CAGE for routine primary care screening because of their broader sensitivity across the spectrum of alcohol use disorders.

The DSM-5 defines alcohol use disorder (AUD) as a problematic pattern of alcohol use leading to clinically significant impairment or distress, manifested by at least 2 of 11 criteria within a 12-month period. These criteria span impaired control (drinking more or longer than intended, persistent desire to cut down, craving), social impairment (failure to fulfil role obligations, giving up activities, continued use despite interpersonal problems), risky use (recurrent use in hazardous situations, continued use despite physical/psychological problems), and pharmacological features (tolerance, withdrawal).

Severity is graded by criterion count: 2–3 criteria = mild, 4–5 = moderate, 6 or more = severe. The CAGE was developed before the DSM-5 framework and does not map directly onto these criteria, but a positive CAGE screen should prompt formal assessment using DSM-5 criteria to confirm a diagnosis and determine severity.

A positive CAGE screen (score ≥2) should trigger a structured brief intervention, which has strong evidence for reducing alcohol consumption in primary care settings. The brief intervention model often follows the FRAMES framework:

• Feedback — provide personalised feedback about the patient’s drinking and its health consequences
• Responsibility — emphasise that the choice to change rests with the patient
• Advice — offer clear, non-judgemental advice to reduce or cease drinking
• Menu — offer a menu of options for change rather than a single prescription
• Empathy — use motivational interviewing techniques; express empathy and avoid confrontation
• Self-efficacy — support the patient’s belief in their ability to change

For patients with CAGE scores of 3–4 or evidence of dependence, brief intervention alone is typically insufficient and referral to specialist addiction services is recommended, along with assessment of withdrawal risk if cessation is planned.

When a patient screens positive on the CAGE — particularly with a positive Eye-opener response — withdrawal risk should be assessed if the patient has recently reduced or stopped drinking, or if hospitalisation will interrupt regular alcohol consumption.

Key features suggesting withdrawal risk include: daily or near-daily drinking, drinking large quantities, morning drinking (the Eye-opener), a history of previous withdrawal episodes (especially seizures or delirium tremens), and co-existing benzodiazepine use. The CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, Revised) is a validated tool for monitoring and guiding pharmacological management of withdrawal once it has begun.

In hospitalised patients, a positive CAGE should prompt the clinical team to consider prophylactic withdrawal management, especially in surgical patients where alcohol use may not have been disclosed.

Emergency department (ED) presentations offer a critical opportunity for alcohol screening, as many patients present with alcohol-related injuries, medical complications, or intoxication. Studies have shown that ED-based alcohol screening and brief intervention reduces subsequent alcohol consumption and injury recurrence.

The CAGE can be integrated into the ED assessment workflow, but its limitation is that it may miss acute hazardous drinking without dependence features — an important pattern in the ED population (e.g. binge-drinking young adults who present with injuries). The AUDIT-C or a single-question screen (“How many times in the past year have you had 5 or more drinks in a day?” for men, or 4 or more for women) may be more appropriate as an initial ED screen, with the CAGE reserved for patients with suspected dependence.

The most common error is interpreting a positive CAGE score as a confirmed diagnosis of alcohol use disorder. The CAGE is a screening instrument — it identifies individuals who need further evaluation, not those who definitively have a disorder. A score of 2 does not mean “the patient has alcohol dependence”; it means the probability of an alcohol use disorder is substantially elevated and a thorough clinical assessment is warranted.

Conversely, a score of 0 does not rule out problematic drinking. A young binge drinker who has not yet experienced guilt, social criticism, or morning withdrawal will screen negative despite consuming at hazardous levels.

Clinicians often avoid asking about alcohol use due to concern about offending patients, seeming judgemental, or lack of time. However, evidence consistently demonstrates that patients generally accept alcohol screening when it is presented as a routine part of a medical assessment. Framing the questions with a normalising preamble — such as “I ask all my patients about their drinking as part of a health check” — reduces discomfort for both parties.

The CAGE is designed to be embedded in a conversational history. It does not require a formal questionnaire and can be woven naturally into a review of lifestyle habits alongside questions about smoking, diet, and exercise.

While the standard threshold for a positive screen is ≥2, a single positive “Eye-opener” response deserves attention even with a total score of 1. Morning drinking to relieve tremor, anxiety, nausea, or other withdrawal symptoms is a feature of physiological dependence. It is relatively uncommon in people who do not have a significant alcohol problem and has a high positive predictive value for dependence when present in isolation.

A patient who endorses only the Eye-opener may be minimising other responses. Consider gently exploring the other domains in more depth if this item is positive.

A positive CAGE screen should always be followed by questions about the quantity and frequency of alcohol use. The CAGE tells you there may be a problem, but it does not tell you how much or how often the patient drinks — information essential for risk stratification, withdrawal risk assessment, and treatment planning.

Ask about: typical number of standard drinks per drinking occasion, drinking days per week, maximum drinks in a single episode in the past month, and the date of last drink. This information, combined with the CAGE result, provides a much more complete clinical picture than either alone.

The CAGE questions are typically phrased in the “have you ever…” format, which captures lifetime experience rather than current behaviour. A patient with a remote history of alcohol dependence who has been in sustained recovery for years may score 3 or 4 based on past experiences. This is clinically relevant information (history of alcohol use disorder confers ongoing relapse risk), but it does not indicate current active drinking.

Always clarify the temporal context: “Are these experiences recent, or from the past?” and “When did you last have a drink?” This distinguishes active problems from historical ones and guides the urgency of further assessment.