CAGE: Cut down, Annoyed, Guilty, Eye opener
Expansion
CAGE:
- C - Cut down: have you ever felt you should cut down on your drinking?
- A - Annoyed: have people annoyed you by criticising your drinking?
- G - Guilty: have you ever felt bad or guilty about your drinking?
- E - Eye opener: have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
Two or more positive answers is a positive screen. CAGE detects dependence better than it detects hazardous drinking, so AUDIT or AUDIT-C is preferred for screening in primary care and the emergency department.
Quantifying intake: one unit is 10 ml or 8 g of pure alcohol. The UK guidance is no more than 14 units per week for all adults, spread over three or more days, with alcohol free days. A pint of ordinary strength beer is about 2 units, a 175 ml glass of wine about 2, and a single measure of spirits 1.
Features of dependence
- Compulsion to drink
- Primacy of drinking over other activities
- Tolerance
- Withdrawal symptoms, and drinking to relieve them
- A narrowed repertoire, drinking the same thing at the same times
- Reinstatement after abstinence
Withdrawal timeline: tremor, sweating and anxiety at 6 to 12 hours; seizures at 12 to 48 hours; delirium tremens at 48 to 72 hours, which carries appreciable mortality. Pabrinex should be given to prevent Wernicke’s encephalopathy, and before any glucose load.