The Cut down, Annoyed, Guilty, Eye opener-Adapted to Include Drugs (CAGE-AID) questionnaire may not always correctly identify patients at risk for nonmedical opioid use (NMOU), as highlighted by 2 cases, including 1 in a patient with cholangiocarcinoma (CCA), published in the Annals of Palliative Medicine.

In the report, 2 cases involved male patients seeking treatment for cancer-related pain, including a man in his 40s with metastatic CCA and biliary obstruction with 2 external biliary drains and a man in his 60s with metastatic prostate cancer. The patient with CCA was admitted with uncontrolled pain, intractable nausea, and vomiting.

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The man was admitted 24 hours after being discharged from another hospital where he had stayed for 2 weeks. He reported pain and nausea scores of 10/10, and his CAGE-AID score was negative (0 out of 4), so he was started on oral hydromorphone for moderate pain and intravenous hydromorphone for severe pain along with intravenous ondansetron and metoclopramide for nausea. The patient began to refuse oral pain medication due to nausea and would use multiple intravenous administrations.

The patient began to request more frequent intravenous administrations and that the nurses administer it more rapidly into his central line rather than the slower standard 2-minute administration. The staff recommended oral painkillers, but the patient became irritated when they would not follow his demands for intravenous administration when imaging showed stable disease without a reason for increased pain.

The patient eventually left the hospital when it became clear that the staff would no longer be administering intravenous hydromorphone. The patient’s demands, behaviors, and frequent hospitalizations were all consistent with NMOU.

In the case of the patient with prostate cancer, the patient had clear evidence of cancer progression to his lumbar spine, but he had a CAGE-AID score of 3 out of 4. The positive CAGE-AID score led to concerns about NMOU and resulted in a slower titration of pain medication and subsequent poor pain management for the patient. Further follow-up with the patient’s wife revealed that the patient answered “yes” to questions about alcohol use due to concerns that it may have contributed to his cancer diagnosis despite him only using it occasionally at social events.

“Our cases highlight that the CAGE-AID questionnaire should be used only as a screening tool and not to diagnose NMOU,” the authors wrote.

“It is essential to interpret its results and other screening tools with caution and in conjunction with clinical findings, regular monitoring of prescription drug monitoring program, and conducting random urine drug screens. Management changes solely based on the CAGE-AID questionnaire might result in undertreating pain or worsening NMOU,” the researchers concluded.


Amaram-Davila J, Bramati P, Gammon L, et al. Deficiencies with CAGE-AID questionnaire in identifying nonmedical opioid use—report of two cases. Ann Palliat Med. Published online August 22, 2023. doi:10.21037/apm-23-192