CAGE questionnaire: scoring, CAGE-AID, and when to escalate

In this article▾

1. What is the CAGE questionnaire?
2. How to score the CAGE questionnaire
3. What does a CAGE score of 1 mean?
4. What does a CAGE score of 2 mean?
5. What does a CAGE score of 3 or 4 mean?
6. CAGE-AID: The drug-adapted version
7. CAGE vs. CAGE-AID
8. When should a clinician escalate after a positive CAGE?
9. When should a CAGE-positive patient be referred?
10. Why CAGE is not a complete alcohol-use screen
11. CAGE questionnaire documentation
12. CAGE and medical necessity
13. Common CAGE questionnaire mistakes
14. CAGE questionnaire quick reference
15. CAGE-AID quick reference
16. Frequently asked questions about the CAGE questionnaire
17. Final takeaway
18. Sources

The CAGE questionnaire is a four-item screening tool for identifying possible problems related to alcohol use. Each question receives 1 point for a "yes" response and 0 for "no," producing a total score from 0 to 4.

The four letters stand for:

• C = Cut down
• A = Annoyed by criticism
• G = Guilty
• E = Eye-opener

CAGE is brief and easy to administer, but it has an important limitation: a positive CAGE score is not a diagnosis of alcohol use disorder (AUD), and a negative score does not rule out unhealthy alcohol use.

The CAGE questions focus largely on consequences and dependence-related experiences rather than quantity or frequency of drinking. Current U.S. guidance from NIAAA and the USPSTF favors other brief screening approaches, such as the AUDIT-C or a single-question screen, when the goal is to identify the broader spectrum of unhealthy alcohol use.

What is the CAGE questionnaire?

CAGE was introduced by John Ewing in 1984 as a four-question clinical interview tool focused on cutting down, annoyance by criticism, guilt, and morning "eye-opener" drinking.

The original questionnaire is designed around lifetime experience, rather than a defined recent period. That means a patient who had an alcohol problem years ago can still screen positive even if they are no longer drinking.

The four questions are:

All four questions are asked, and each "yes" scores 1 point.

How to score the CAGE questionnaire

Scoring is simple:

• Yes = 1 point
• No = 0 points
• Maximum = 4 points

Add the four responses to calculate the total score.

CAGE score interpretation

A score of 2 or more is the conventional positive threshold and indicates that further assessment is warranted.

The cutoff is not universal. In primary care, a threshold of 1 positive response is commonly used when the goal is to identify more people who may have a substance-use problem, at the cost of more follow-up assessments.

A positive CAGE screen should lead to assessment, not an automatic diagnosis.

What does a CAGE score of 1 mean?

A score of 1 means the patient answered "yes" to one of the four questions.

It does not establish AUD.

The clinical significance depends partly on why the patient screened positive and what the rest of the substance-use history shows.

For example, a patient who reports needing a morning drink to steady their nerves has answered "yes" to the eye-opener question. That warrants substantially more assessment than simply recording "CAGE = 1."

A structured history framework helps here. OLDCARTS covers onset, duration, timing and severity, which are the elements a screening score leaves out. The clinician should follow up on:

• Current alcohol use
• Quantity and frequency
• Pattern of heavy drinking
• Time of last drink
• Withdrawal symptoms
• Previous withdrawal complications
• Consequences of use
• Attempts to cut down
• Current motivation and treatment needs

A one-positive threshold can increase sensitivity, but it also means more patients will require follow-up assessment.

What does a CAGE score of 2 mean?

A score of 2 meets the conventional CAGE cutoff for a positive screen.

It means the patient endorsed two of the four lifetime questions. It does not tell the clinician whether the patient currently meets criteria for AUD, how severe the disorder is, or whether the patient requires a particular treatment setting.

The appropriate next step is a more complete assessment.

The USPSTF specifically recommends follow-up assessment after a positive brief alcohol screen rather than using the screening result as the endpoint.

What does a CAGE score of 3 or 4 mean?

Scores of 3 or 4 represent multiple positive responses and should prompt further evaluation.

The score still does not quantify:

• Current drinking
• Frequency of drinking
• Typical quantity
• Recent heavy-drinking episodes
• Current withdrawal risk
• Current functional impairment
• DSM-5-TR AUD symptom count

This is one reason the CAGE should not be used by itself to determine diagnosis or level of care.

A high CAGE score means that the clinician should look more closely, not that the patient automatically has severe AUD.

CAGE-AID: The drug-adapted version

CAGE-AID stands for CAGE Adapted to Include Drugs.

It uses the same four-question structure but expands each question to cover alcohol and drug use, including illegal drugs and prescription medication used other than as prescribed.

The four domains remain:

• Cut down
• Annoyed by criticism
• Guilty
• Eye-opener

The difference is that the questions refer to drinking or drug use rather than alcohol alone.

The University of Washington's National HIV Curriculum likewise describes CAGE-AID as an adaptation intended to screen conjointly for alcohol and drug problems. It considers one or more "yes" responses a positive screen requiring further evaluation.

How to score CAGE-AID

The scoring remains:

• Yes = 1
• No = 0
• Maximum = 4

One or more positive responses is the commonly used positive screen for CAGE-AID. Brown and Rounds' validation study reported sensitivity 0.79 and specificity 0.77 at one or more positive responses, against 0.70 and 0.85 at two or more. Their conclusion was that CAGE-AID is more sensitive but less specific than CAGE for substance abuse, particularly at the reduced criterion score, which is exactly the trade those two number pairs describe.

Sources: Brown and Rounds (1995), Wisconsin Medical Journal · Ewing (1984), JAMA

The important clinical point is that CAGE-AID is a screening instrument, not a way to determine which substance use disorder a patient has or its severity.

CAGE vs. CAGE-AID

The CAGE-AID should not be treated as a completely different instrument. It is an adaptation of the CAGE in which the substance-use reference is broadened. Brown and Rounds developed the conjoint version for alcohol and other drug problems.

When should a clinician escalate after a positive CAGE?

A positive screen is the start of the clinical pathway.

A useful sequence is:

Positive CAGE/CAGE-AID → substance-use assessment → risk assessment → diagnostic formulation → treatment/referral decision

Step 1: Clarify current use

The CAGE does not tell you how much the patient currently drinks or uses drugs.

Ask about:

• Frequency
• Typical quantity
• Maximum quantity
• Heavy-use episodes
• Route of administration where relevant
• Time of last use
• Recent changes in use
• Attempts to cut down
• Consequences of use

This is particularly important because the CAGE is oriented toward consequences and dependence-related experiences and may identify people with past problems rather than current problematic use.

Step 2: Assess withdrawal and immediate medical risk

A positive screen should prompt questions about withdrawal history when clinically relevant.

Ask whether the patient has experienced:

• Tremor
• Sweating
• Nausea or vomiting
• Anxiety or agitation
• Withdrawal-related hallucinations
• Seizures
• Delirium or severe confusion
• Previous medically supervised withdrawal

An "eye-opener" response deserves particular follow-up because it may indicate a history of drinking to relieve morning withdrawal symptoms. Where current withdrawal is a possibility, the CIWA-Ar is the instrument that quantifies it.

If the patient has signs of acute withdrawal, a history of severe withdrawal, or other acute medical concerns, the next step is not simply another screening questionnaire. The patient needs appropriate clinical evaluation and management.

Step 3: Assess psychiatric and safety risk

Substance use can coexist with acute psychiatric or safety concerns.

Escalate the evaluation when the clinical picture includes:

• Suicidal ideation or recent self-harm
• Severe psychiatric symptoms
• Significant cognitive impairment
• Psychosis
• Severe intoxication
• Acute behavioral instability
• Risk of harm to self or others

The CAGE does not assess these domains. They require separate clinical assessment.

Step 4: Determine whether a diagnostic assessment is needed

A positive screen is not the same as an AUD or other SUD diagnosis.

The clinician should assess the applicable diagnostic criteria and determine whether the patient has a current disorder and, when applicable, its severity.

NIAAA's current clinical workflow separates screening for heavy drinking from subsequent assessment of alcohol use disorder symptoms.

Step 5: Determine the appropriate treatment setting

A CAGE score should not be converted directly into an ASAM level of care.

The ASAM Criteria Fourth Edition uses a multidimensional assessment to identify clinical needs and apply those findings to level-of-care criteria. Its dimensions cover intoxication and withdrawal, biomedical conditions, psychiatric and cognitive conditions, substance-use-related risks, recovery environment, and person-centered considerations. Our level of care assessment guide walks through how that is scored.

So the pathway is not:

CAGE 3 → residential

It is:

CAGE positive → comprehensive assessment → identify risks and needs → determine appropriate level of care

That distinction is important both clinically and for utilization review.

When should a CAGE-positive patient be referred?

Referral depends on what the follow-up assessment shows.

Further outpatient assessment may be appropriate when:

• The patient has a positive screen but no acute safety concerns.
• Current use requires further diagnostic clarification.
• The patient has clinically significant consequences but can be safely assessed in the current setting.
• Brief intervention, motivational work, or outpatient SUD treatment may be appropriate.

More urgent evaluation may be appropriate when:

• The patient may be experiencing alcohol withdrawal.
• There is a history of withdrawal seizures or delirium.
• There is significant medical instability.
• There is severe intoxication or impaired consciousness.
• There are acute psychiatric or safety concerns.
• The patient's current environment cannot safely support the necessary monitoring.

The CAGE score itself does not determine which of these pathways applies.

Why CAGE is not a complete alcohol-use screen

This is an important point for clinicians using an older but familiar tool.

NIAAA's wording is blunter than most summaries of it. Its clinician resource tells readers to avoid the still widely used but outdated CAGE as a screening tool, and says the USPSTF does not recommend CAGE for screening because it does not identify all patients who could benefit from a brief intervention. The reason it gives is the one worth remembering: CAGE only captures patients already experiencing adverse consequences of heavy drinking, so you miss many prevention opportunities.

NIAAA points clinicians to the AUDIT-C or a single-question screen instead, both of which ask about heavy drinking days and take one to two minutes.

Sources: NIAAA: screen and assess · USPSTF: unhealthy alcohol use screening

This does not make CAGE useless.

It means clinicians should understand what question CAGE is actually answering.

CAGE is useful for identifying a history suggestive of problematic alcohol use and prompting further evaluation. It is less useful for answering:

"Is this patient currently drinking at a risky level?"

or

"How much does this patient drink?"

or

"Does this patient meet DSM-5-TR criteria for AUD?"

Those questions require additional assessment.

CAGE questionnaire documentation

A positive screen should be documented with enough detail to show what was actually assessed and what happened next.

At minimum, document:

• Instrument used
• Date administered
• Individual responses
• Total score
• Cutoff applied
• Current substance-use assessment
• Relevant withdrawal or safety findings
• Diagnostic assessment or next step
• Referral or treatment plan when indicated

Example: CAGE-positive documentation

CAGE administered today. Score 2/4, with positive responses for cut down and guilt. Patient reports current alcohol use 4-5 days/week and approximately 4-6 drinks per drinking day. Denies history of withdrawal seizure or delirium. Further AUD assessment completed. Discussed treatment options and patient referred for outpatient SUD evaluation.

This is much more clinically useful than:

"CAGE = 2, positive."

Example: CAGE-AID documentation

CAGE-AID administered. Score 2/4, with positive responses related to criticism and desire to cut down. Patient reports current alcohol use and nonmedical use of a prescription medication. Further assessment completed regarding frequency, quantity, route, consequences, and last use. Treatment referral discussed.

Again, the note should reflect what was actually assessed.

CAGE and medical necessity

A CAGE score does not establish medical necessity for a particular level of SUD treatment.

For a patient being evaluated for IOP, PHP, residential treatment, or another intensive service, the clinical record should explain the patient's actual needs.

That can include:

• Current substance-use pattern
• Diagnostic criteria and severity
• Withdrawal or intoxication risk
• Biomedical complications
• Psychiatric or cognitive conditions
• Functional impairment
• Relapse or continued-use risk
• Recovery environment
• Previous treatment and response
• Why the requested service is appropriate

The ASAM Criteria Fourth Edition uses a multidimensional assessment to support level-of-care recommendations and emphasizes reassessment as patients move through the continuum. Our guides to Level 2.1 intensive outpatient and Level 3.5 residential cover what each setting has to document.

The CAGE is therefore best viewed as one piece of the assessment, not the justification for the treatment setting itself.

For related guidance, see our ASAM Criteria glossary entry, the alcohol use disorder ICD-10 guide and the alcohol dependence ICD-10 guide. If the screen leads to a withdrawal-management admission, CIWA-Ar scoring and the medical necessity entry cover what the record has to carry.

Common CAGE questionnaire mistakes

1. Treating a positive CAGE as an AUD diagnosis

A positive screen requires further assessment. It does not establish a DSM-5-TR diagnosis.

2. Using CAGE to quantify drinking

CAGE does not ask about quantity or frequency.

Follow a positive screen with questions about current drinking patterns.

3. Assuming a negative CAGE rules out unhealthy alcohol use

It does not.

CAGE can miss hazardous or risky drinking that has not yet produced the consequences represented by its questions.

4. Ignoring the lifetime nature of the questions

A patient can screen positive because of a problem that occurred years ago.

Clarify whether the substance-use problem is current, historical, or both.

5. Treating CAGE-AID as a diagnostic instrument

CAGE-AID is a conjoint alcohol and drug screen. A positive result requires further evaluation.

6. Using the CAGE score to assign ASAM level of care

A CAGE score does not determine treatment placement.

Use a multidimensional clinical assessment and the applicable ASAM criteria.

7. Documenting the score without the next step

Document the score, the threshold applied, and the assessment or referral that followed. A score on its own does not show a reviewer what happened next.

CAGE questionnaire quick reference

CAGE-AID quick reference

Frequently asked questions about the CAGE questionnaire

What does CAGE stand for?

CAGE stands for Cut down, Annoyed, Guilty, and Eye-opener. These correspond to the four domains assessed by the questionnaire.

What is a positive CAGE score?

Traditionally, 2 or more positive responses is considered a positive CAGE screen. Some clinical settings use 1 or more to increase sensitivity and identify more patients for further assessment. The appropriate threshold should follow the screening protocol being used.

Is a CAGE score of 2 diagnostic of alcoholism?

No. A score of 2 is a positive screening result, not a diagnosis. Further assessment is required to determine whether the patient has a current alcohol use disorder and what treatment needs are present.

What is CAGE-AID?

CAGE-AID is the CAGE Adapted to Include Drugs. It modifies the four CAGE questions to refer to alcohol and drug use. One or more positive responses is considered a positive screen on the commonly used CAGE-AID scoring approach.

Does CAGE-AID screen for prescription drug misuse?

Yes. The drug-use component covers illegal drugs and prescription medication used other than as prescribed, so nonmedical use of a prescribed opioid, stimulant or benzodiazepine is in scope.

Is CAGE still recommended for alcohol screening?

CAGE remains a widely recognized clinical instrument, but current NIAAA guidance advises against using it as the primary screening tool for unhealthy alcohol use because it can miss patients who could benefit from early intervention. The USPSTF favors more sensitive approaches such as AUDIT-C or a single-question screen for initial screening.

What should I use instead of CAGE?

NIAAA points clinicians to the AUDIT-C or a single-question screen about heavy drinking days. Both take one to two minutes and both ask about consumption, which is the thing CAGE does not measure. CAGE remains useful for the history it does capture, but it is not the tool for finding people before consequences appear.

Who developed the CAGE questionnaire?

John Ewing, in a 1984 JAMA paper describing four clinical interview questions focused on cutting down, annoyance by criticism, guilty feelings and eye-openers. The acronym was built to help a physician recall them.

Is CAGE-AID better than CAGE?

Better at finding people, worse at ruling them out. Brown and Rounds found CAGE-AID more sensitive but less specific than CAGE for substance abuse, especially at the lower cutoff. Which trade you want depends on what happens to a positive screen in your setting.

When should a positive CAGE result be escalated?

Escalate from screening to a more complete assessment whenever CAGE is positive. Urgency increases when there are signs of withdrawal, previous severe withdrawal, significant medical complications, acute psychiatric or safety concerns, severe intoxication, or other factors suggesting that the patient needs a higher level of clinical support.

The CAGE score itself should not be used as an automatic treatment-placement threshold.

Final takeaway

The CAGE questionnaire is a four-item screen that can quickly identify a history suggestive of problematic alcohol use.

Its strengths are its brevity and simplicity. Its limitations are equally important:

• It is primarily a consequence/dependence-oriented screen.
• It does not quantify current drinking.
• Its questions are commonly framed around lifetime experience.
• A positive result is not a diagnosis.
• A negative result does not rule out unhealthy alcohol use.
• It should not determine ASAM level of care by itself.

CAGE-AID uses the same four-item structure for alcohol and drug use and is generally considered positive with one or more "yes" responses.

For clinicians, the most useful pathway is:

Screen → assess current use → assess withdrawal and safety → establish diagnosis when appropriate → determine treatment needs → match level of care.

That makes the CAGE questionnaire what it is intended to be: a brief entry point into a more complete clinical assessment, not the endpoint.

Sources

1. Ewing, J. A. (1984). Detecting alcoholism: The CAGE questionnaire. JAMA, 252(14), 1905-1907. pubmed.ncbi.nlm.nih.gov
2. Brown, R. L., & Rounds, L. A. (1995). Conjoint screening questionnaires for alcohol and other drug abuse: Criterion validity in a primary care practice. Wisconsin Medical Journal, 94(3), 135-140. pubmed.ncbi.nlm.nih.gov
3. National Institute on Alcohol Abuse and Alcoholism. Screen and assess: Use quick, effective methods. niaaa.nih.gov
4. U.S. Preventive Services Task Force. Unhealthy alcohol use in adolescents and adults: Screening and behavioral counseling interventions. uspreventiveservicestaskforce.org
5. American Society of Addiction Medicine. The ASAM Criteria, Fourth Edition. asam.org

Related guides: CIWA-Ar scoring · COWS scoring · Alcohol use disorder ICD-10 · Alcohol dependence ICD-10 · ASAM levels of care

Every source above was opened and checked on October 4, 2026. This is educational content and does not replace the published instrument, your organization's screening protocol, or clinical judgment.