Following a hypoxic-ischemic insult, the globus pallidus is selectively spared from ischemic injury in contrast to the caudate and putamen. The known causes for hemorrhagic and necrotic lesions selective for injuring the globus pallidus are varied but few. The most widely known etiology is in fatal cases of carbon monoxide poisoning. Additionally reported associations include fatalities involving 3,4-methylenedioxymethamphetamine; cocaine; opiates; and cyanide poisoning. These bilateral globus palladus necrotic lesions have been reported to occur in 5-10% of opiate addicts. In this article, we present a striking photo of selective symmetrical bilateral globus pallidus necrosis following cocaine and opiate abuse.