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CORK Bibliography: CAGE Screening Test

34 citations. 2003 to present

Prepared: June 2012

Aertgeerts B; Buntinx F; Kester A. The value of the CAGE in screening for alcohol abuse and alcohol dependence in general clinical populations: A diagnostic meta-analysis. Journal of Clinical Epidemiology 57(1): 30-39, 2004. (79 refs.)

Objective: To perform a meta-analysis to assess diagnostic characteristics of the CAGE in screening for alcohol abuse or dependence in a general clinical population and to test a new method for pooling of ROC curves. Methods: Medline search performed over the period 1/1/1974 to 31/12/2001. Measurement: Calculation of diagnostic values. Results: We identified 35 articles using the DSM criteria as the gold standard to test the diagnostic value of the CAGE. Only 10 studies could be included for the meta-analysis. With a cutoff point greater than or equal to2, the pooled sensitivity is far better in inpatients (0.87) than in primary care patients (0.71) or ambulatory patients (0.60). The pooled specificity also differs for each group. The likelihood ratios seem to be relatively constant over the populations (overall LR+:3.44;LR-:0.18). We calculated a pooled AUC of 0.87 (95% CI 0.85-0.89). At low specificity values, the sensitivity was homogenous over the studies, and at a low sensitivity, the specificity was heterogenous. Conclusion: The diagnostic value of the CAGE is of limited value using this test for screening purposes at his recommended cutpoint of greater than or equal to2.

Alexander T; DiNitto DM; Tidblom I. Screening for alcohol and other drug use problems among the deaf. Alcoholism Treatment Quarterly 23(1): 63-78, 2005

No alcohol and other drug screening or diagnostic instruments have been validated for Deaf populations, although screening tools exist in other languages, such as Spanish. Deaf individuals traditionally have had difficulty understanding tests created for hearing populations because they contain wording or phrases that are unfamiliar in Deaf culture. The purpose of this study was to lay the groundwork for developing a culturally relevant alcohol and other drug screening instrument for Deaf individuals. Deaf individuals were asked about their understanding of items from two widely-used screening instruments, the CAGE and the AUDIT, which were developed for hearing individuals. Deaf participants reported difficulty with both instruments, with some words problematic for 88% of participants. Providers using these instruments should be aware of their limitations when used with Deaf individuals.

Barry KL; Blow FC; Willenbring M; McCormick R; Brockmann LM; Visnic S. Use of alcohol screening and brief interventions in primary care settings: Implementation and barriers. Substance Abuse 25(1): 27-36, 2004. (42 refs.)

Although evidence indicates that brief alcohol screening and interventions are effective across primary care settings, implementation of these techniques has been problematic. The primary objective of this study was to determine current practices and barriers for screening and interventions with primary care patients across randomly selected clinics in a large health care system, the Veterans Health Administration. Focus groups and mailed structured surveys were used. Results from providers indicated that 85% of patients treated in primary care received some screening for alcohol use disorders. The CAGE was the predominant screening tool. The primary clinical focus was on treatment referrals for patients who met abuse/dependence criteria. Lack of time was the most important perceived barrier to implementing screening and brief alcohol interventions for at-risk and problem drinkers. Implications for implementation of screening and intervention programs for a range of drinkers (at-risk use, problem use, abuse, dependence) are discussed.

Bataille V; Ruidavets JB; Arveiler D; Amouyel P; Ducimetiere P; Perret B; Ferrieres J. Joint use of clinical parameters, biological markers and CAGE questionnaire for the identification of heavy drinkers in a large population-based sample. Alcohol and Alcoholism 38(2): 121-127, 2003. (38 refs.)

Aims: Alcohol consumption in France is one of the highest in the world. Factors associated with excessive alcohol drinking are numerous. However, taken separately, none of the existing clinical or biological markers of excessive alcohol intake enables an adequate identification of heavy drinkers. The aim of this cross-sectional survey was to identify socio-demographic, clinical and biological factors associated with excessive alcohol drinking, to develop a model and to assess its reliability, thus enabling the detection of heavy drinkers. Methods: Subjects were 1619 men and 1559 women, aged 35-64 years, living in three French areas (Lille, Strasbourg and Toulouse) and randomly selected from polling lists. Socio-demographic status, lifestyle, reported alcohol intake and answers to the CAGE questionnaire (alcohol dependence) were obtained by questionnaire. A blood sample was taken for quantification of biological parameters. Men who drank 60 g of ethanol a day (g/day) or above and women who drank 30 g/day or above were classified as heavy drinkers. The reference class (RC) gathered non-drinkers and moderate drinkers together. The sample was divided into two sub-samples: the first was used to estimate the parameters of a logistic regression model (heavy drinkers vs others), and the second to assess the accuracy of this model for the identification of heavy drinkers, using receiver operating characteristic (ROC) curves. A specific analysis was performed for each gender. Results: Fourteen per cent of men and 40.8% of women were non-drinkers. Nine per cent of women and 14.4% of men were heavy drinkers. Wine was the most consumed alcoholic beverage. In the univariate analyses, differences were observed between the two groups of alcohol consumers for most of the socio-demographic, clinical and biological variables considered. In the multivariate analyses, low educational level, smoking, apoprotein B, high density lipoprotein cholesterol, mean corpuscular volume (MCV), gamma-glutamyl-transferase (GGT) and the CAGE score for men, and living area, age, MCV, GGT and the CAGE score for women remained independently and significantly associated with heavy drinking. In the validation sub-sample, these models combining different types of markers enabled a good discrimination between heavy drinkers and the RC, with an area under the ROC curve of 82% for men and of 79% for women. Conclusions: In this study, socio-demographic, clinical and biological factors and the CAGE score were independently related to excessive alcohol drinking and their joint utilization in a screening model enabled a good recognition of heavy drinkers.

Berks J; McCormick R. Screening for alcohol misuse in elderly primary care patients: A systematic literature review. (review). International Psychogeriatrics 20(6): 1090-1103, 2008. (45 refs.)

Background: Alcohol problems in the elderly are common and frequently undetected, and therefore a potential target for a screening program. Method: Using Medline, Psychinfo and reference lists from relevant publications, articles were identified testing pen-and-paper screens in the primary care population aged over 60 years. Results: Using standard definitions of alcohol problems, conventional screens adapted for use in the elderly have performances similar to screens in the younger primary care population. However, it can be argued that special screens perform better for the elderly. Conclusions: The Alcohol Use Disorders Identification Test is a useful screen for detecting harmful and hazardous drinking in the elderly while the CAGE is valuable when screening for dependence. In the future, the Alcohol-Related Problems Survey, a computer-based screen, may prove to be superior if practical implementation problems can be overcome.

Burns E; Gray R; Smith LA. Brief screening questionnaires to identify problem drinking during pregnancy: A systematic review. (review). Addiction 105(4): 601-614, 2010. (80 refs.)

Aims: Although prenatal screening for problem drinking during pregnancy has been recommended, guidance on screening instruments is lacking. We investigated the sensitivity, specificity and predictive value of brief alcohol screening questionnaires to identify problem drinking in pregnant women. Methods: Electronic databases from their inception to June 2008 were searched, as well as reference lists of eligible papers and related review papers. We sought cohort or cross-sectional studies that compared one or more brief alcohol screening questionnaire(s) with reference criteria obtained using structured interviews to detect 'at-risk' drinking, alcohol abuse or dependency in pregnant women receiving prenatal care. Results: Five studies (6724 participants) were included. In total, seven instruments were evaluated: TWEAK (Tolerance, Worried, Eye-opener, Amnesia, Kut down), T-ACE [Take (number of drinks), Annoyed, Cut down, Eye-opener], CAGE (Cut down, Annoyed, Guilt, Eye-opener], NET (Normal drinker, Eye-opener, Tolerance), AUDIT (Alcohol Use Disorder Identification Test), AUDIT-C (AUDIT-consumption) and SMAST (Short Michigan Alcohol Screening Test). Study quality was generally good, but lack of blinding was a common weakness. For risk drinking sensitivity was highest for T-ACE (69-88%), TWEAK (71-91%) and AUDIT-C (95%), with high specificity (71-89%, 73-83% and 85%, respectively). CAGE and SMAST performed poorly. Sensitivity of AUDIT-C at score >= 3 was high for past year alcohol dependence (100%) or alcohol use disorder (96%) with moderate specificity (71% each). For life-time alcohol dependency the AUDIT at score >= 8 performed poorly. Conclusion: T-ACE, TWEAK and AUDIT-C show promise for screening for risk drinking, and AUDIT-C may also be useful for identifying alcohol dependency or abuse. However, their performance as stand-alone tools is uncertain, and further evaluation of questionnaires for prenatal alcohol use is warranted.

Chang G. Screening and brief intervention in prenatal care settings. Alcohol Research & Health 28(2): 80-84, 2004. (24 refs.)

Pregnant women continue to drink despite evidence that prenatal alcohol consumption can negatively affect fetal growth and development. Because no universally safe level of prenatal alcohol use has been established, it is beneficial to identify and modify a woman's prenatal alcohol use early in her pregnancy, particularly as her past drinking habits can predict her drinking levels during pregnancy. Some women may voluntarily disclose the extent of their prenatal alcohol consumption. if not, the T-ACE, a four-item screening questionnaire based on the CAGE assessment tool, has been demonstrated to be a valuable and efficient method for identifying a range of alcohol use. Studies have shown that combined with brief interventions, early identification of a woman's prenatal alcohol use could avert its more severe adverse consequences and may be the logical first-line approach.

Public Domain

Cherpitel CJ; Ye Y; Moskalewiez J; Swiatkiewicz G. Screening for alcohol problems in two emergency service samples in Poland: Comparison of the RAPS4, CAGE and AUDIT. Drug and Alcohol Dependence 80(2): 201-207, 2005. (37 refs.)

Prior research on alcohol-related problems among emergency service patients in Poland found Substantial alcohol involvement on the part of injured males. suggesting emergency services may be a productive venue for identifying patients who could benefit from a brief intervention or referral for treatment. Performance of the RAPS4, CAGE and AUDIT against ICD-10 and DSM-IV criteria for alcohol dependence and for alcohol abuse/harmful drinking was compared in probability samples of emergency service patients from two regions of Poland. Sensitivity of the RAPS4 and AUDIT was significantly better than the CAGE for alcohol dependence among males in Warsaw, but specificity was poorer. Among females, although numbers were small, sensitivity for alcohol abuse/harmful drinking and for alcohol dependence or abuse/harmful drinking was significantly better for the RAPS4-QF than for the CAGE or AUDIT at a cut point of 8 across both sites. Performance of the AUDIT at a cut point of 3 was similar to the RAPS4-QF for females. Among males, sensitivity was higher but specificity considerably lower for the RAPS4-QF compared to the CAGE at a Cut point of I or for the AUDIT at a cut point of 8. Alternate cut points for the AUDIT optimized performance. Findings suggest some regional and gender differences in performance of screening instruments in these Polish samples, but no instrument or cut point is optimal in identifying those with alcohol use disorders. Additional cross-cultural research is needed to evaluate the performance of instruments, especially among females with alcohol use disorders.

Cook RL; Chung T; Kelly TM; Clark DB. Alcohol screening in young persons attending a sexually transmitted disease clinic: Comparison of AUDIT, CRAFFT, and CAGE instruments. Journal of General Internal Medicine 20(1): 1-6, 2005. (33 refs.)

OBJECTIVE: To compare the ability of 3 brief alcohol screens (Alcohol Use Disorders Identification Test [AUDIT], CRAFFT, and CAGE) to identify adolescents and young adults with a current alcohol use disorder (AUD) and to determine whether there are gender-based or race-based differences in screening performance. DESIGN, PARTICIPANTS AND SETTING: Cross-sectional study of 358 young persons (55% males; 49% blacks; age range, 15-24 years; mean age, 20.6 years) who were attending an urban clinic for sexually transmitted diseases and reported alcohol use during the past year. MEASUREMENTS: Receiver operating characteristic (ROC) curve analysis was used to determine the ability of the 3 screens to discriminate between participants with and without AUDs detected in the Structured Clinical Interview for DSM-IV (SCID). RESULTS: One third (33%) of participants met Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria for a current AUD (24% with alcohol abuse and 9% with alcohol dependence). The AUDIT performed best at a cut score of 9 (sensitivity, 0.76; specificity, 0.79), CRAFFT at a cut score of 2 (sensitivity, 0.94; specificity, 0.33), and CAGE at a cut score of 1 (sensitivity, 0.69; specificity, 0.63). The AUDIT had the best overall performance (area under the curve [AUC], 0.84), followed closely by CRAFFT (AUC, 0.79) and then CAGE (AUC, 0.70). Performance of screens did not differ by gender. The AUDIT performed slightly better in whites than blacks, but no race-based differences were observed for the CAGE or CRAFFT. CONCLUSIONS: Clinicians should use the AUDIT or CRAFFT, rather than the CAGE, to screen young persons for AUDs. The AUDIT performs best, but its length may limit its utility in this setting. The CRAFFT is a suitable alternative, with excellent sensitivity and no gender-based or race-based differences.

Cremonte M; Ledesma RD; Cherpitel CJ; Borges G. Psychometric properties of alcohol screening tests in the emergency department in Argentina, Mexico and the United States. Addictive Behaviors 35(9): 818-825, 2010. (45 refs.)

The objective of this article is to report psychometric characteristics of the AUDIT, CAGE, RAPS4, and TWEAK and to compare them across three countries: Argentina, Mexico, and the United States which used a similar protocol and methodology. Probability samples of patients 18 years and older were drawn from emergency departments in Mar del Plata, Argentina (n = 780), Pachuca, Mexico (n=1624) and Santa Clara, U.S. (n=1220). Concurrent validity was assessed by comparing their performance against a diagnosis of alcohol dependence (DSM-IV) obtained through the Composite International Diagnostic Interview, and for the briefer measures, also by their correlation with the AUDIT. The internal consistency of the CAGE, RAPS4, and TWEAK scores was estimated by the KR-20 formula and by Cronbach's Alpha for the AUDIT. Corrected item-total correlation and D-values were used as item discrimination measures. In Argentina and Mexico the AUDIT and the RAPS4 showed the highest validity. Reliability of all instruments was higher in the US than in Argentina or Mexico. In all three countries, reliability of the TWEAK was lowest, while the AUDIT was highest. With a few exceptions, all items showed good discrimination powers.

Dervaux A; Bayle FJ; Laqueille X; Bourdel MC; Leborgne M; Olie JP. Validity of the CAGE questionnaire in schizophrenic patients with alcohol abuse and dependence. Schizophrenia Research 81(2-3): 151-155, 2006. (35 refs.)

The objective of the study was to assess the sensitivity and the specificity of the CAGE questionnaire in 114 schizophrenic patients. The Composite International Diagnostic Interview was used to assess the DSM-III-R diagnosis of abuse of or dependence on alcohol. The CAGE questionnaire can be reliably used to assess alcohol use disorders in schizophrenic patients: with a cutoff score of I or more, the sensitivity of the CAGE questionnaire was 0.91 and the specificity was 0.83. With a cutoff score of 2 or more, the sensitivity of the CAGE questionnaire was 0.82 and the specificity was 0.94. The post test probabilities (PPV) were high (PPV1=0.74; PPV2=0.85) compared to the primary probability of alcoholism (29.8%).

Dev R; Parsons HA; Palla S; Palmer JL; Del Fabbro E et al. Undocumented alcoholism and its correlation with tobacco and illegal drug use in advanced cancer patients. Cancer 117(19): 4551-4556, 2011. (23 refs.)

BACKGROUND: The objectives of this retrospective study were to determine the frequency of undiagnosed alcoholism among patients with advanced cancer who were referred to palliative care and to explore its correlation with alcoholism, tobacco abuse, and use of illegal drugs. METHODS: The authors reviewed 665 consecutive charts and identified 598 patients (90%) who completed a screening survey that was designed to identify alcoholism, the Cut Down, Annoyed, Guilty, Eye Opener (CAGE) questionnaire, including 100 consecutive patients who had CAGE-positive and CAGE-negative results. Data on tobacco and illegal drug use, the Edmonton Symptom Assessment Scale, and the morphine equivalent daily dose were collected. RESULTS: The frequency of CAGE-positive results in this palliative care population was 100 of 598 patients (17%). Only 13 of 100 patients (13%) in that CAGE-positive group had been identified as alcoholics before their palliative care consultation. Compared with CAGE-negative patients, CAGE-positive patients were younger (aged 58.6 years vs 61.3 years; P=.07), predominantly men (68 of 100 patients vs 51 of 100 patients; P=.021), more likely to have a history of tobacco use (86 of 100 patients vs 48 of 100 patients; P<.001), more likely to be actively using nicotine (33 of 100 patients vs 9 of 100 patients; P=.02), and more likely to have a history of illegal recreational drug use (17 of 100 patients vs 1 of 100 patients; P<.001). Pain and dyspnea were worse in patients who had a history of nicotine use. Both CAGE-positive patients and patients who had a history of tobacco use more frequently were receiving strong opioids at the time of their palliative care consultation. CONCLUSIONS: The current findings suggested that alcoholism is highly prevalent and frequently under-diagnosed in patients with advanced cancer. CAGE-positive patients were more likely to have a history of, or to actively engage in, smoking and illegal recreational drug use, placing them at risk for inappropriate opioid escalation and abuse.

Dhalla S; Kopec JA. The CAGE questionnaire for alcohol misuse: A review of reliability and validity studies. (review). Clinical and Investigative Medicine 30(1): 33-41, 2007. (37 refs.)

Purpose: To review the reliability and validity of the CAGE questionnaire across different patient populations and discuss its role in the detection of alcohol- related problems. Methods: The Cochrane Database for Systematic Reviews, Medline, Embase, and Psychinfo were searched. No systematic reviews were found on the Cochrane Database. Search of the other databases yielded one systematic review and one meta-analysis, on different aspects of CAGE. Three articles on reliability and 16 on validity of CAGE were found and used. Studies generally yielded Level II evidence. Results: CAGE has demonstrated high test- retest reliability (0.80-0.95), and adequate correlations (0.48-0.70) with other screening instruments. The questionnaire is a valid tool for detecting alcohol abuse and dependence in medical and surgical inpatients, ambulatory medical patients, and psychiatric inpatients (average sensitivity 0.71, specificity 0.90). Its performance in primary care patients has been varied, while it has not performed well in white women, prenatal women, and college students. Furthermore, it is not an appropriate screening test for less severe forms of drinking. Conclusions: CAGE is short, feasible to use, and easily applied in clinical practice. However, users should be aware of its limitations when interpreting the results. A positive screen should be followed by a proper diagnostic evaluation using standard clinical criteria.

do Amaral RA; Malbergier A. Effectiveness of the CAGE questionnaire, gamma-glutamyltransferase and mean corpuscular volume of red blood cells as markers for alcohol-related problems in the workplace. Addictive Behaviors 33(6): 772-781, 2008. (28 refs.)

Objective: To evaluate the usefulness of gamma-glutamyltransferase (GGT) and mean corpuscular volume (MCV), as well as that of the CAGE questionnaire, in workplace screening for alcohol abuse/dependence. Methods: A total of 183 male employees were submitted to structured interviews (Structured Clinical Interview for DSM-IV 2.0 and CAGE questionnaire). Blood samples were collected. Diagnostic accuracy and odds ratio were determined for the CAGE, GGT and MCV. Results: The CAGE questionnaire presented the best sensitivity for alcohol dependence (91%; specificity, 87.8%) and for alcohol abuse (87.5%, specificity, 80.9%), which increased when the questionnaire was used in combination with GGT (sensitivity, 100% and 87.5%, respectively; specificity, 68% and 61.5, respectively). CAGE positive results and/or alterations in GGT were less likely to occur among employees not presenting alcohol abuse/ dependence than among those presenting such abuse (OR for CAGE = 13, p < 0.05; OR for CAGE-GGT = 11, p < 0.05) or dependence (OR for CAGE = 76, p < 0.0 1; OR for GGT = 5, p < 0.0 1). Employees not presenting alcohol abuse/dependence were also several times more likely to present negative CAGE or GGT results. Conclusions: The use short, simple questionnaires, combined with that of low-cost biochemical markers, such as GGT, can serve as an initial screening for alcohol-related problems, especially for employees in hazardous occupations. The data provided can serve to corroborate clinical findings.

Etter JF. Asking about quantity and frequency of alcohol consumption before asking the CAGE questions produces lower ratings on the CAGE test. Drug and Alcohol Dependence 74(2): 211-214, 2004. (16 refs.)

Background: We tested whether asking about alcohol consumption before asking the CAGE questions modified the answers to the CAGE test. Methods: Randomized trial on a smoking cessation website, in English, in 2003. Half the participants began by answering questions on quantity and frequency of alcohol consumption and then, on a second web page, answered the CAGE questionnaire (format A). The other half answered first the CAGE and then questions on quantity and frequency (format B). Results: The survey was answered by 1213 people. Fewer people gave positive answers to three of the four CAGE questions in format A than in format B. Cut-down, 32% versus 38% (P = 0.01); annoyed, 13% versus 18% (P = 0.02); eye-opener, 5% versus 8% (P = 0.02). Fewer people had a CAGE score greater than or equal to 2, indicating possible alcoholism, in format A than in format B (26% versus 32%, P = 0.04). This effect was stronger in men (CAGE greater than or equal to 2, format A, 29%; format B, 39%; P = 0.03), and it was not statistically significant in women (CAGE greater than or equal to 2, format A, 25%; format B, 28%; P = 0.4). Conclusion: In an internet survey, asking questions about the quantity and frequency of alcohol consumption before asking the CAGE questionnaire produced fewer positive answers to the CAGE. This effect was observed only in men.

Etter M; Etter JF. Alcohol consumption and the CAGE test in outpatients with schizophrenia or schizoaffective disorder and in the general population. Schizophrenia Bulletin 30(4): 947-956, 2004. (65 refs.)

We conducted a survey of 151 outpatients with schizophrenia or schizoaffective disorder in Geneva, Switzerland, in 2000, and a mail survey in a representative sample of the general population of Geneva in 1996 (n = 742), to compare alcohol consumption and alcoholism in these two samples. Fewer patients with schizophrenia than participants in the general population drank alcohol daily (9.9% vs. 18.3%, p < 0.001). Excluding participants who said they currently never drank, alcohol consumption was similar in both groups (3 vs. 4 glasses/week, p = 0.22). However, more patients with schizophrenia than participants in the population sample had a CAGE score >= 2 (21.2% vs. 10.1%, p < 0.001), indicating a suspicion of alcoholism. Thus, asking about alcohol consumption produced different results from assessing hidden alcoholism with the CAGE. Either patients with schizophrenia underreported their alcohol consumption, or the CAGE produced higher scores in these patients, for any given level of alcohol consumption. Previous research has shown, however, that the CAGE is a valid test in patients with schizophrenia, which suggests that in Geneva, alcoholism is more prevalent in patients with schizophrenia than in the general population.

Public Domain

Hesse M; Thiesen H. The CAGE as a measure of hazardous drinking in the homeless. American Journal on Addictions 16(6): 475-478, 2007. (25 refs.)

The aim of this study was to test the validity of the CAGE questions as a measure of severe drinking in subjects at drop-in centers for the homeless, using biological markers of acute liver reaction to alcohol as the "gold standard.'' A sample of homeless men and women in Copenhagen were invited to participate in a study of health problems. Subjects were interviewed and blood samples were taken and screened for indicators of liver dysfunction (gamma-glutamyltransferase [gamma GT], mean corpuscular volume [MCV], alanine aminotransferase [ALAT], and alkaline phosphatase [Alpase]), and hepatitis C [HCV]. Scores on CAGE correlated strongly with years of heavy drinking ( rho 0.43, p < 0.001), and while years of drinking did not correlate with biomarkers after controlling for multiple hypothesis testing, CAGE correlated with gamma GT, Alpase and ALAT, but not MCV. The correlations held even among those without HCV, but subjects with HCV+ and CAGE > 1 had quite extreme values on liver markers. Findings suggested that the CAGE was able to identify homeless drinkers whose drinking was signifantly associated with increases in biomarkers associated with heavy drinking.

Johnson TP Hughes TL. Reliability and concurrent validity of the CAGE screening questions: A comparison of lesbians and heterosexual women. Substance Use & Misuse 40(5): 657-669, 2005. (27 refs.)

Although lesbians are believed to be at heightened risk for alcohol abuse and alcohol dependency, the reliability and validity of currently available screening measures have yet to be explored in this population group. In this paper, we report the psychometric properties of the CAGE in a diverse sample of 63 lesbians and comparisons with a control group of 57 heterosexual women. Data were collected in Chicago during 19971998 1 using face-to-face interviews. Findings suggest that the CAGE has good reliability and concurrent validity among lesbians. One CAGE item, concerned with drinking in the morning, however, was found to be only weakly associated with the other items among lesbians. Although this pilot study is limited by the nonprobability sample, we conclude that evaluating the appropriateness of other alcohol and drug abuse measures in high-risk populations, such as lesbians, should be a research priority.

Kelly TM; Donovan JE; Chung T; Cook RL; Delbridge TR. Alcohol use disorders among emergency department-treated older adolescents: A new brief screen (RUFT-Cut) using the AUDIT, CAGE, CRAFFT, and RAPS-QF. Alcoholism: Clinical and Experimental Research 28(5): 746-753, 2004. (43 refs.)

Background: Early identification of alcohol use disorders (AUD) among emergency department (ED)-treated patients is important for facilitating intervention and further evaluation outside EDs. A number of brief screening instruments have been developed for identifying patients with AUD, but it is not clear whether they are practical and perform well with older adolescents in an ED setting. This study contrasted four brief screening instruments for detecting DSM-IV-defined AUD and tested a newly developed brief screen for use among ED-treated older adolescents.Methods: The Alcohol Use Disorders Identification Test (AUDIT), the CAGE, the CRAFFT, and a modified RAPS-QF were given to 93 alcohol-using older adolescents (55% men; aged 18-20 years) in an ED. Receiver operator characteristic analyses were used to evaluate the performance of brief screens against the criterion of a lifetime DSM-IV alcohol abuse or dependence diagnosis.Results: Of existing instruments, the AUDIT had the best overall performance in identifying AUD (sensitivity, 82%; specificity, 78%). A new, shorter screening instrument composed of two AUDIT items, two CRAFFT items, and one CAGE item (RUFT-Cut) performed as well as the AUDIT (sensitivity, 82%; specificity, 78%).Conclusions: Among existing alcohol screening instruments, the AUDIT performed best for identifying ED-treated older adolescents with alcohol use disorders. The RUFT-Cut is a brief screening instrument for AUD that shows promise for identifying ED-treated older adolescents who are in need of intervention or further evaluation. Future research should focus on use of the RUFT-Cut in other settings with larger, more diverse samples of adolescents.

Knight JR; Sherritt L; Harris SK; Gates EC; Chang G. Validity of brief alcohol screening tests among adolescents: A comparison of the AUDIT, POSIT, CAGE, and CRAFFT. Alcoholism: Clinical and Experimental Research 27(1): 67-73, 2003. (48 refs.)

Background: Adolescents should be screened for alcohol misuse as part of routine care. The objective of this study was to compare the criterion validity of the Alcohol Use Disorders Identification Test (AUDIT), the Problem Oriented Screening Instrument for Teenagers substance use/abuse scale (POSIT), and the CAGE and CRAFFT questions among adolescents. Methods: Fourteen- to 18-year-old patients arriving for routine healthcare at a large, hospital-based adolescent clinic completed the four screens and the criterion standard Adolescent Diagnostic Interview, which yields DSM-IV diagnoses of alcohol abuse and dependence. Receiver operating characteristic (ROC) curves were plotted to determine optimal cut-points. Areas under the ROC curves of the four screens were compared, and sensitivities and specificities were calculated. Results: Participants' past 12-month alcohol diagnostic classifications were as follows: no use (58.6%), nonproblem use (13.0%), problem use (20.8%), abuse (5.4%), and dependence (2.2%). Optimal cut-points associated with problem use or higher were 2 for AUDIT, I for POSIT, 1 for CAGE, and 1 for CRAFFT. ROC curve area of the CAGE was significantly lower compared with areas of all other screens. Sensitivities (95% confidence intervals) were AUDIT 0.88 (0.83-0.93), POSIT 0.84 (0.79-0.90), CAGE 0.37 (0.29-0.44), and CRAFFT 0.92 (0.88- 0.96); specificities were AUDIT 0.81 (0.77-0.85), POSIT 0.89 (0.86-0.92), CAGE 0.96 (0.94-0.98), and CRAFFT 0.64 (0.59- 0.69). Conclusions: The AUDIT, POSIT, and CRAFFT have acceptable sensitivity for identifying alcohol problems or disorders in this age group. The CAGE is not recommended for use among adolescents.

Koppes LLJ; Twisk JWR; Snel J; Van Mechelen W; Kemper HCG. Comparison of short questionnaires on alcohol drinking behavior in a nonclinical population of 36-year-old men and women. Substance Use & Misuse 39(7): 1041-1060, 2004. (22 refs.)

Little is known on the diagnostic characteristics of brief questionnaires on alcohol drinking behaviors. This report investigates the determinants of three short alcohol questionnaires and investigates their diagnostic utility as screening tools for alcohol-related problems in a general population from The Netherlands. This report uses cross-sectional data obtained in the year 2000 from 36-year-old healthy male (N = 166) and female (N = 165) volunteers who reported to drink alcohol at least occasionally. Since they were 13-years-old these volunteers have been members of the Amsterdam Growth And Health Longitudinal Study, which started as a school-based study in 1977. Among many other variables, quantity-frequency questions (QF), the CAGE questionnaire, and a question on the highest number of alcoholic units consumed on one occasion during the previous month (MAX) were asked. The sensitivity, specificity, Cohen's kappa, and diagnostic odds ratio of QF, CAGE, MAX, and combinations of these three brief questionnaires were calculated using a 7-item questionnaire on alcohol-related problems as reference. Both in women and men, the prevalence of most alcohol-related problems and of a high QF, CAGE, and MAX was low. QF, CAGE, and MAX, as well as all possible combinations of the three questionnaires, were poor in detecting last-year alcohol-related problems. The CAGE appeared to perform worse than the even shorter and easier-to-interpret QF and MAX. In this healthy population of 36-year-old men and women, using the QF, MAX, and especially the CAGE questionnaire as screening instruments for alcohol-related problems resulted in many false positive and false negative classifications.

Malet L; Schwan R; Boussiron D; Aublet-Cuvelier B; Llorca PM. Validity of the CAGE questionnaire in hospital. European Psychiatry 20(7): 484-489, 2005. (32 refs.)

Objective. - The CAGE questionnaire is considered a useful screening and case-finding tool for alcohol use disorders in clinical populations. Our objectives were to validate the French version of the CAGE against DSM-IV criteria and to assess performance of each item of the scale. Method. - Data were extracted from a hospital morbidity study conducted in central France. It concerned 5452 patients-48.5% men-in short and medium-stay units. Patients answered the CAGE questionnaire as a past-year assessment. The alcohol use disorders were diagnosed by the physicians using DSM-IV alcohol abuse or dependency criteria. Results. - The CAGE questionnaire for a cut-off of 2 had a sensitivity of 77% and a specificity of 94%. The CAGE test was more sensitive for patients diagnosed as alcohol-dependent than for alcohol abusers (61 % vs. 84%) with the same specificity (94%). These values are close to those for the English-language CAGE. The first three items (CAG) were very similar, with sensitivity 70% and specificity 94%. The eye-opening question (E) differentiated sharply between abuse and dependency, with sensitivities of 18% and 46%, respectively. A questionnaire comprising only the CAG questions of the CAGE had properties similar to the full questionnaire. Conclusion. - CAGE is a good screening tool for alcohol abuse or alcohol dependency. Given the frequent-and insufficiently diagnosed-alcohol problems among inpatients, CAGE is indicated as a first-line tool for screening for the most severe alcohol use disorders in hospital. It should ideally be used systematically. A positive reply to any of the first three items should alert the clinician and prompt further investigation.

Matano RA; Koopman C; Wanat SF; Whitsell SD; Borggrefe A; Westrup D. Assessment of binge drinking of alcohol in highly educated employees. Addictive Behaviors 28(7): 1299-1310, 2003. (46 refs.)

This study evaluated the usefulness of the Alcohol Use Disorders Identification Test (AUDIT) and CAGE, a standardized screening instrument for detecting alcohol dependence in identifying binge drinking among highly educated employees. Brochures were mailed to an entire workforce inviting employees to learn about their coping strategies, stress levels, and risk for alcohol-related problems, with 228 employees providing complete data. Binge drinking in the previous 3 months was reported by 29% of the employees, with greater binge drinking reported by White employees, of mixed/other ethnic background, or younger. The AUDIT achieved a sensitivity of 35% in identifying respondents who reported binge drinking and a specificity of 98% in accurately identifying respondents who did not report binge drinking. Sensitivity using the cut-off of scoring one or more positive hits on the CAGE was 67%, and specificity was 84%. Therefore, neither the AUDIT nor the CAGE achieved adequate sensitivity, as well as specificity, as screening tools for assessing binge drinking. A more accurate method for assessing binge drinking appears to be by directly asking for the largest number of drinks consumed in a single drinking session.

Mengel MB; Searight HR; Cook K. Preventing alcohol-exposed pregnancies. (review). Journal of the American Board of Family Medicine 19(5): 494-505, 2006. (103 refs.)

Fetal alcohol exposure affects approximately 1% to 3% of live births in the United States. Family physicians are in a unique position to reduce the incidence of alcohol-exposed pregnancy. Fetal alcohol exposure can be minimized through 2 general approaches: reducing alcohol consumption or increasing effective contraception among childbearing-aged women who engage in "at-risk" drinking and encouraging pregnant women to abstain from alcohol. Although no safe level of alcohol consumption during pregnancy is established, women who binge drink are more likely to deliver infants with physical and cognitive-developmental anomalies. Screening tools, such as quantity/frequency questions, the TWEAK and the T-ACE, developed specifically for prenatal care, are more useful with women than the CAGE and Michigan Alcohol Screening Test (MAST). Screening alone seems to reduce alcohol use among pregnant women. Brief interventions, including education about alcohol's effects on the developing fetus, are effective among women not responding to screening. Unfortunately, many barriers exist to effective implementation of alcohol-exposed pregnancy (AEP) prevention in the clinical setting. Designing effective office base systems so the entire burden of implementing AEP prevention activities doesn't fall solely on the family physician is critical.

Moraes CL; Viellas EF; Reichenheim ME. Assessing alcohol misuse during pregnancy: Evaluating psychometric properties of the CAGE, T-ACE and TWEAK in a Brazilian setting. Journal of Studies on Alcohol 66(2): 165-173, 2005. (73 refs.)

Objective: The present article evaluates the psychometric properties of the Portuguese-language versions of the CAGE, TWEAK and T-ACE questionnaires when used to identify alcohol misuse during pregnancy and compares these to historical data from the English-language versions. Also, construct validity of the Portuguese versions of those instruments was assessed. Method: Data were collected from March to September 2000 in three large public maternity wards in Rio de Janeiro, Brazil. Sample size varied according to the analysis. An intra-observer reliability evaluation involved 95 replications carried out within a 24-48 hour period. Kappa was used as an estimator. Cronbach's alpha coefficient, whether or not each item from the analysis was excluded, and the item-rest point-biserial correlations addressed internal consistency (N = 786). For the appraisal of construct validity (n = 528), the relationship between alcohol misuse (evaluated by each instrument according to different cutoff points) and several putative underlying theoretically related dimensions (schooling, age, smoking, marital status, social support, illicit drug use, domestic violence and per capita household income) were evaluated. Results: All kappas were above 0.70. The alpha coefficients for the Portuguese versions ranged from 0.48 to 0.68, a finding consistent with studies assessing the original instruments in English. Yet, irrespective of the instrument concerned, a systematic increase was observed whenever the item on morning alcohol use ("Eye-opener") was removed from the analysis. Regarding construct validity, most tested hypotheses were corroborated, except for the CAGE using the cut-off point of 2. Conclusions: This study confirms other authors' findings that all but the aforementioned CAGE may be recommended to identify heavy alcohol use during pregnancy in general as well as in Portuguese-speaking populations in particular.

O'Brien CP. The CAGE Questionnaire for detection of alcoholism: A remarkably useful but simple tool (Reprinted from JAMA, vol 252, pg 1905-1907, 1984) reprint. Journal of the American Medical Association 300(17): 2054-2056, 2008. (12 refs.)

This is a reprint of the article outlining the use of four questions to screen for alcohol dependence, a tool known as the CAGE. "Four clinical interview questions, the CAGE questions, have proved useful in helping to make a diagnosis of alcoholism. The questions focus on Cutting down, Annoyance by criticism, Guilty feeling, and Eye-openers. The acronym 'CAGE' helps the physician to recall the questions. How these questions were identified and their use in clinical and research studies are described." (from the original article)

Philpot M; Pearson N; Petratou V; Dayanandan R; Silverman M; Marshall J. Screening for problem drinking in older people referred to a mental health service: A comparison of CAGE and AUDIT. Aging & Mental Health 7(3): 171-175, 2003. (26 refs.)

The aim of the study was to evaluate the validity of the Alcohol Use Disorders Identification Test (AUDIT), the five-item version (AUDIT-5) and the CAGE as screening tests for problem drinking in mentally ill older people. The study was of prospective cross-sectional design with questionnaire survey and interview and included all consecutive referrals to an old age psychiatry service fulfilling inclusion criteria. Sensitivity, specificity and positive predictive values and areas under the receiver operating characteristic curves (AUROC) for the AUDIT, AUDIT-5, and CAGE were the primary outcome measures. Using clinical criteria as the gold standard, the AUDIT, AUDIT-5 and CAGE had AUROCs of 0.961, 0.964, and 0.780 respectively. The AUDIT-5 performed best of the three scales with a sensitivity of 75.0%, specificity of 97.2% and positive predictive value of 83.3% when using a 4/5 cut-point. The AUDIT-5 performed as well as the AUDIT and better than the CAGE in identifying problem drinking in this sample. The AUDIT-5 may be a useful addition to the specialist mental health assessment of older people.

Reid MC; Tinetti ME; O'Connor PG; Kosten TR; Concato J. Measuring alcohol consumption among older adults: A comparison of available methods. American Journal on Addictions 12(3): 211-219, 2003. (28 refs.)

We determined levels of agreement and concordance between five alcohol measures among older veterans from a VA primary care clinic (N = 303) and community-dwelling Medicare beneficiaries (N = 511). 511). The individuals recruited for the study had not been previously identified for alcohol use. Quantity-frequency questions, a binge drinking question, the Alcohol Use Disorders Identification Test, CAGE, and questions on lifetime consumption were administered to all current drinkers. To assess agreement between the measures, we conducted pairwise comparisons (eg, QF vs. CAGE) by determining the percentage of participants who screened positive on both measures and calculated kappa values to determine concordance. Only modest levels of agreement and concordance were found between the measures. The use of any individual measure may fail to detect many older adults with important alcohol exposures. Until optimal methods for measuring alcohol exposures in elderly adults are defined, we suggest that a combination of measures be used when obtaining alcohol histories in older persons.

Rubinsky AD; Kivlahan DR; Volk RJ; Maynard C; Bradley KA. Estimating risk of alcohol dependence using alcohol screening scores. Drug and Alcohol Dependence 108(1-2): 29-36, 2010. (47 refs.)

Brief alcohol counseling interventions can reduce alcohol consumption and related morbidity among non-dependent risky drinkers, but more intensive alcohol treatment is recommended for persons with alcohol dependence. This study evaluated whether scores on common alcohol screening tests could identify patients likely to have current alcohol dependence so that more appropriate follow-up assessment and/or intervention could be offered. This cross-sectional study used secondary data from 392 male and 927 female adult family medicine outpatients (1993-1994). Likelihood ratios were used to empirically identify and evaluate ranges of scores of the AUDIT, the AUDIT-C, two single-item questions about frequency of binge drinking, and the CAGE questionnaire for detecting DSM-IV past-year alcohol dependence. Based on the prevalence of past-year alcohol dependence in this sample (men: 12.2%; women: 5.8%), zones of the AUDIT and AUDIT-C identified wide variability in the post-screening risk of alcohol dependence in men and women, even among those who screened positive for alcohol misuse. Among men, AUDIT zones 5-10, 11-14 and 15-40 were associated with post-screening probabilities of past-year alcohol dependence ranging from 18 to 87%, and AUDIT-C zones 5-6, 7-9 and 10-12 were associated with probabilities ranging from 22 to 75%. Among women, AUDIT zones 3-4, 5-8, 9-12 and 13-40 were associated with post-screening probabilities of past-year alcohol dependence ranging from 6 to 94%, and AUDIT-C zones 3, 4-6, 7-9 and 10-12 were associated with probabilities ranging from 9 to 88%. AUDIT or AUDIT-C scores could be used to estimate the probability of past-year alcohol dependence among patients who screen positive for alcohol misuse and inform clinical decision-making.

Samet JH; Phillips SJ; Horton NJ; Traphagen ET; Freedberg KA. Detecting alcohol problems in HIV-infected patients: Use of the CAGE questionnaire. AIDS Research and Human Retroviruses 20(2): 151-155, 2004. (45 refs.)

The HIV epidemic has been consistently associated with injection drug use and crack cocaine, but alcohol problems in HIV-infected persons are less well described. Our objectives were 2-fold: (1) to assess the prevalence of alcohol problems in HIV-infected patients initiating medical care; and (2) to determine the positive predictive value of the CAGE questionnaire for alcohol abuse or dependence in HIV-infected patients. Between July 1997 and October 2000, we assessed a consecutive series of patients who were establishing primary care for HIV infection (clinic sample), using an established alcohol screening test, the CAGE questionnaire. In addition, we enrolled other HIV-infected patients, including some of the clinic sample, who had two or more positive responses to the CAGE questionnaire into a longitudinal cohort (cohort sample), performed a diagnostic interview for lifetime history of alcohol abuse and dependence, and determined the positive predictive value of CAGE for alcohol diagnoses. In the clinic sample (n = 664), 42% (276 of 664) had two or more positive responses to the four CAGE questions. In the cohort sample (n = 141)9 95% (134 of 141) met DSM-IV criteria for diagnosis of lifetime alcohol abuse or dependence. For patients initiating HIV primary care, a history of alcohol problems is very common. The CAGE questionnaire identifies a lifetime history of alcohol abuse or dependence in HIV-infected patients. Routine screening for alcohol problems should be performed in all patients entering HIV medical care and the CAGE questions are useful in this setting.

Shields AL; Caruso JC. A reliability induction and reliability generalization study of the CAGE questionnaire. Educational and Psychological Measurement 64(2): 254-270, 2004. (71 refs.)

The CAGE is a commonly used alcohol screening instrument. Although considerable work has been done on the validity of CAGE scores, relatively little information is available on their reliability. Reliability induction and generalization studies were performed for the CAGE. Of the 259 studies available for analysis, only 19 (7.3%) contained reliability information for the sample scores. Thirteen (5.0%) and 227 (87.6%) articles made what are designated as reliability induction by report and reliability induction by omission. The median internal consistency reliability across 22 samples was .74, with a range of .52 to .90. Sample age was the only identified sample characteristic that demonstrated a statistically significant relationship with CAGE score reliability.

Skogen JC; Overland S; Knudsen AK; Mykletun A. Concurrent validity of the CAGE questionnaire. The Nord-Trondelag Health Study. Addictive Behaviors 36(4): 302-307, 2011. (43 refs.)

The aim of this study was to examine the psychometric properties of the CAGE questionnaire, and the questionnaire's concurrent validity with current and previous alcohol consumption. This study employed data from the Nord-Trondelag Health Survey wave 1 (HUNT-1 in 1984-86: N = 24,900) and wave 2 (HUNT-2 in 1995-97: N=36,350). The concurrent validity of the CAGE questionnaire was examined both as a dichotomous variable with the recommended cut-off (>= 2 affirmative answers) for alcohol problems, and as a categorical scale. The categorical scale was constructed by counting responses from 0 to 4, and a separate category for current abstainers in HUNT-2. Current self-reported consumption above the gender specific 80th percentile was defined as "current excessive consumption". "Previous excessive consumers" were defined by meeting at least one of the two following criteria at the time of HUNT-1: reporting drinking too much alcohol in any period of their life, or reporting a high level of alcohol consumption. The internal reliability of CAGE was adequate, and in relation to alcohol consumption, there was a linear relationship between the CAGE score and both the current and previous excessive consumption. In conclusion, this study indicates good concurrent validity and adequate psychometric properties of the CAGE questionnaire. The dose-response pattern seen between the CAGE score and alcohol consumption, suggests that it can be used as an ordinal measure, rather than with a cut-off of two or more. The concurrent validity of the CAGE is better in women than in men.

Gache P; Michaud P; Landry U; Accietto C; Arfaoui S; Wenger O et al. The Alcohol Use Disorders Identification Test (AUDIT) as a screening tool for excessive drinking in primary care: Reliability and validity of a French version. Alcoholism: Clinical and Experimental Research 29(11): 2001-2007, 2005. (43 refs.)

Background: Excessive drinking is a major problem in Western countries. AUDIT (Alcohol Use Disorders Identification Test) is a 10-item questionnaire developed as a transcultural screening tool to detect excessive alcohol consumption and dependence in primary health care settings Objectives: The aim of the study is to validate a French version of the Alcohol Use Disorders Identification Test (AUDIT) Methods: We conducted a validation cross-sectional study in three French-speaking areas (Paris, Geneva and Lausanne). We examined psychometric properties of AUDIT as its internal consistency, and its capacity to correctly diagnose alcohol abuse or dependence as defined by DSM-IV and to detect hazardous drinking (defined as alcohol intake > 30 g pure ethanol per day for men and > 20 g of pure ethanol per day for women). We calculated sensitivity, specificity, positive and negative predictive values and Receiver Operator Characteristic curves. Finally, we compared the ability of AUDIT to accurately detect "alcohol abuse/dependence" with that of CAGE and MAST Results: 1207 patients presenting to outpatient clinics (Switzerland, n = 580) or general practitioners' (France, n = 627) successively completed CAGE, MAST and AUDIT self-administered questionnaires, and were independently interviewed by a trained addiction specialist. AUDIT showed a good capacity to discriminate dependent patients (with AUDIT 13 for males, sensitivity 70.1%, specificity 95.2%, PPV 85.7%, NPV 94.7% and for females sensitivity 94.7%, specificity 98.2%, PPV 100%, NPV 99.8%); and hazardous drinkers (with AUDIT 7, for males sensitivity 83.5%, specificity 79.9%, PPV 55.0%, NPV 82.7% and with AUDIT >= 6 for females, sensitivity 81.2%, specificity 93.7%, PPV 64.0%, NPV 72.0%). AUDIT gives better results than MAST and CAGE for detecting "Alcohol abuse/dependence" as showed on the comparative ROC curves. Conclusions: The AUDIT questionnaire remains a good screening instrument for French-speaking primary care.

Sorocco KH; Ferrell SW. Alcohol use among older adults. Journal of General Psychology 133(4): 453-467, 2006. (46 refs.)

Alcohol use problems among older adults have been called the "invisible epidemic." As the population of older adults continues to grow, there is an increased need to reexamine alcohol use in this population. The authors provide an overview on alcohol use in the over-60 age group. The main areas of focus included research on the prevalence of drinking in that population, as well as comments on the best practices in assessment and psychological treatment. Several screening assessments have been recommended for use with older adults, such as the CAGE questionnaire, Michigan Alcohol Screening Test-Geriatric version, Alcohol-Related Problems Survey, and the Alcohol Use Disorders Identification Test. The authors note age-appropriate psychological treatment interventions that include brief interventions, family interventions, motivational counseling, and cognitive behavioral therapies. Barriers to assessment and treatment are also discussed.