A mechanism for rapid death in
cocaine abusers is proposed based on the
neuroleptic malignant syndrome (NMS). The mechanism involves decreased postsynaptic availability of
dopamine either through direct receptor blockade, as postulated in classical NMS, or through relative
dopamine depletion, as postulated in
cocaine withdrawal. The hallmark symptoms of NMS include
hyperpyrexia and
muscular rigidity, but the
cocaine associated syndrome is atypical in having minimal rigidity. This lack of
muscle rigidity, however, appears to be consistent with NMS-like syndromes accompanying other conditions involving
dopamine depletion rather than blockade. Treatment implications are that
dopamine antagonists, which are usually prescribed for
cocaine overdose, may be contraindicated and instead,
dopamine agonists may reverse this rapidly fatal syndrome.