Background <p>Opioid use disorder (OUD) is associated with elevated suicide and impulsivity risks, yet the underlying existential vulnerabilities remain underexplored. This study aimed to examine death anxiety and death-related depression as potential mechanisms associated with suicidal ideation and impulsivity in OUD, and to evaluate the protective role of psychological resilience.</p> Methods <p>Participants included 86 individuals with OUD in remission (under buprenorphine/naloxone treatment) and 86 healthy controls. Self-report measures assessed death anxiety, death-related depression, suicidal ideation, impulsivity, and psychological resilience. Data were analyzed using group comparisons and hierarchical regression models.</p> Results <p>While death anxiety did not significantly differ between groups (p = 0.153), the OUD group showed significantly higher death-related depression, suicidal ideation, and impulsivity, alongside lower resilience (p &lt; 0.003). Hierarchical regression analyses revealed that death-related depression positively predicted suicidal ideation (β = 0.278, p = 0.007), whereas psychological resilience demonstrated a significant negative association (β = -0.296, p = 0.002). In the impulsivity model, psychological resilience emerged as the only significant predictor (β = -0.482, p &lt; 0.001).</p> Conclusions <p>Findings suggest that death-related depression, reflecting existential hopelessness rather than threat-based anxiety, represents an overlooked psychological vulnerability closely linked to suicidal ideation in OUD. Psychological resilience acts as a critical protective factor against both suicidal ideation and impulsivity. Interventions targeting meaning-making and resilience may be vital for mitigating suicide risk in this population. </p>