In patients with stroke or TIA who have a substance use disorder (drugs or alcohol), specialized services are recommended to help manage this dependency. Synopsis The PAR for stroke associated with harmful alcohol consumption (>30 drinks per month or binge drinking >5 drinks per day at least once per month) is 3.8%, In addition, binge drinking in those with known hypertension markedly increases cardiovascular mortality risk and is cumulative (HR, CLINICAL STATEMENTS AND GUIDELINES Kleindorfer Alcohol consumption and ischemic stroke have a J-shaped relationship, regardless of sex.162,163 Stroke risk is associated with heavy alcohol consumption (>4 drinks in a day or >14 drinks a week in men; >3 drinks a day or >7 drinks a week in women).18,165 The risk of harmful alcohol consumption in recurrent stroke is not well defined; >60 g/d (>4 drinks a day) has been asso- ciated with stroke recurrence at 90 days,161 matching a meta-analysis of an RR of 1.69 (95% CI, 1.34 2.15) for ischemic stroke at that consumption level.166 The World Drug Report (2017) relates a 23% increase in the number of estimated drug users in 11 years, reach- ing 255 million in 2015.167 A sharp increase in US stroke rates attributable to IE was noted to coincide with the emergent opioid epidemic.168 Evidence sup- porting an association between drug use and ischemic stroke, notably in stimulants and developing in canna- bis use, is emerging18,169 171 and must be addressed in stroke prevention strategies. Recommendation-Specific Supportive Text 1. Although behavioral interventions, for example, the STOP (secondary stroke prevention) trial, can show decreased alcohol consumption levels,141 their impact on recurrent stroke is not delineated. 