Is The CAGE Test Still Relevant?

The CAGE screening tool is a four-question test intended to evaluate the test-taker’s relative risk of having an alcohol use disorder (AUD). “CAGE” is an acronym that corresponds to keywords in each of the test’s four standard questions (cut-annoyed-guilty-eye).¹

Since its introduction in the 1970s, CAGE has been widely adapted for a variety of more specific purposes, most notably for screening drug use disorders or as a more comprehensive diagnostic tool. Classic CAGE is a screening tool meant for facilitating triage and is not intended for diagnostics.²

Though it can be administered by a trained clinician, CAGE is specifically designed to be self-administered by a layperson. Answering all four questions takes less than one minute and the standard test is considered to be reliable. In its intended role, the CAGE test has proven to be credible, even today.²

But given that it’s five decades old, why is it still so popular? It comes down to its blend of simplicity and accuracy.² Here we’ll explore why CAGE continues to endure, especially in its intended purpose.

CAGE Questions

Most CAGE questionnaires have the following four questions or variations of the same.^1,2

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

Each CAGE question can be answered as “yes” or “no” and is worth one point. In most versions, two “yeses” minimum for males and one “yes” for females indicate a higher chance of AUD, warranting full diagnostics facilitated by a qualified psychiatrist. This minimum threshold may vary depending on the facilitator or specific AUD treatment program. Tests have to be completed to be considered valid.^1,2

Who Is CAGE Intended For?

CAGE is meant for laypersons who want to know whether they or someone they know should seek medical attention. Though it lacks the granularity and detail of other AUD screening tests, it is easy to remember, can be answered quickly, and can be performed on oneself or others. The CAGE test could also be performed by clinicians as a pre-screening method before a full diagnostic exam is performed.^1,2

How Reliable Are CAGE Tests?

CAGE tests are widely considered by American clinicians to be reliable enough for their intended purpose. Having only four questions, there are practical limits on how accurate CAGE or most of its variants could be. However, CAGE is more than good enough for determining whether the test taker should seek further medical attention.^1,2

What Are The Limitations of CAGE?

Most types of CAGE tests have the following limitations:

 

• Lacks Detail. As mentioned earlier, the four-question format of most CAGE tests prevents them from showing the detail needed for a diagnosis. This means that it can have problems distinguishing a person with a risk of AUD from someone who is a merely heavy drinker. However, within the context of its use as a screening tool, this is generally not considered problematic unless the test is misapplied.^1,2

 

• May Be Outdated. CAGE was developed before the introduction of the Diagnostic and Statistical Manual of Mental Disorders and several decades before the introduction of the fifth edition (DSM-5). Prior to DSM-5 introducing AUD and other substance use disorders, alcoholism and alcohol abuse were considered separate conditions with their own criteria. However, given the intent of CAGE, this is only a problem when it is misused as a diagnostics tool rather than as a screening test.^2,3

 

• Prone to Social Desirability Bias. CAGE tests that are not self-administered have been shown to be especially prone to social desirability bias. This is a kind of bias when a person changes their answers depending on what they think the other person wants. Accuracy could be improved by shifting to an anonymous format, such as an online test, or by taking the time to earn the test-taker’s trust.^2,4

 

I Scored Positive On CAGE. What’s Next?

Scoring the minimum number of “yeses” (two for a male and one for a female) in CAGE means that further assessment by a qualified psychiatrist may be necessary. You may also want to try other AUD screening tools designed that are designed to be self-administered.^1,2,5

Get Tested for AUD Today

Early detection and treatment of AUD are often key to improving one’s recovery outcomes.⁶ Call our team at Boston Drug Treatment Centers at (857) 577-8193 to discuss your testing and treatment options.

Resources

 

1. Ewing, J. A. (1984).Detecting alcoholism: the CAGE questionnaire. Jama, 252(14), 1905-1907

 

2. Dhalla, S., & Kopec, J. A. (2007). The CAGE questionnaire for alcohol misuse: a review of reliability and validity studies. Clinical and investigative medicine. Medecine clinique et experimentale, 30(1), 33–41. https://doi.org/10.25011/cim.v30i1.447

 

3. National Institute on Alcohol Abuse and Alcoholism. (2020, February). Alcohol Use Disorder: A Comparison Between DSM–IV and DSM–5.

 

4. Zaldívar, F., Molina, A. M., López Ríos, F., & García Montes, J. M. (2009). Evaluation of alcohol and other drug use and the influence of social desirability: Direct and camouflaged measures. European Journal of Psychological Assessment, 25(4), 244-251.

 

5. S. Substance Abuse and Mental Health Services Administration. (n.d.). Examples of Screening and Assessment Tools for Substance Use Disorders.

 

6. U.S. Substance Abuse and Mental Health Services Administration & U.S. Office of the Surgeon General (US. (2016). Early intervention, treatment, and management of substance use disorders. In Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health [Internet]. US Department of Health and Human Services.