Depression and Anxiety Linked to Problematic Opioid Use in Cancer Patients, Iranian Study Finds

A new study from northern Iran has added a sobering data point to one of oncology’s most persistent dilemmas: the entanglement of psychological suffering with the medications meant to relieve physical pain. Researchers at a tertiary referral hospital affiliated with Babol University of Medical Sciences found that among 350 adults with confirmed cancer diagnoses, more than four in ten showed clinically significant symptoms of anxiety, roughly the same proportion showed clinically significant depressive symptoms, and about one in seven screened positive for problematic opioid use. Crucially, the severity of those psychiatric symptoms tracked closely with the severity of problematic opioid use, suggesting that the mind and the prescription pad cannot be treated as separate clinical problems.

The research, published as an open-access paper in Discover Mental Health, was conducted between January and December 2023. Every participant underwent a psychiatric assessment that combined a structured clinical interview based on DSM-5 diagnostic criteria, carried out by a psychiatrist together with a trained medical intern, with two widely used self-report instruments. Anxiety and depression were measured with the Hospital Anxiety and Depression Scale, known as HADS, a fourteen-item questionnaire designed specifically for medically ill patients and deliberately worded to avoid confounding somatic symptoms of illness, such as fatigue or appetite loss, with symptoms of mood disorders. Problematic opioid use was screened with the Drug Abuse Screening Test, or DAST-10, administered with explicit reference to opioid consumption.

The numbers are striking on their own. Using the conventional HADS threshold of eleven or above, which indicates clinically significant symptom burden, 43.5 percent of participants met the cutoff for anxiety and 40.3 percent for depression. Meanwhile, 15.2 percent screened positive for problematic opioid use on the DAST-10. The participants were, on average, 58.39 years old, with a standard deviation of 14.45 years, and 52.9 percent were male. That prevalence of psychological distress is consistent with a broader international literature showing that mood and anxiety disorders are markedly more common among people living with cancer than in the general population, but the concurrent measurement of opioid-related harm is what gives the study its distinctive angle.

When the researchers ran correlation analyses, both psychiatric dimensions emerged as statistically significant positive correlates of problematic opioid use. Anxiety scores on the HADS-A subscale correlated with DAST-10 scores at r = 0.34, and depression scores on the HADS-D subscale correlated at r = 0.28, both with P values below 0.001. In practical terms, patients who reported more severe anxiety or depressive symptoms also tended to report more problematic patterns of opioid use. The correlations are moderate in magnitude, which means the relationship is real and meaningful but far from deterministic; many patients with high distress scores did not screen positive for opioid problems, and some patients with problematic use reported relatively low distress.

To probe the matter further, the team built multivariable linear regression models designed to identify the factors independently associated with anxiety and depression after adjusting for demographic and clinical characteristics. Three variables stood out. Female sex, lower educational attainment, and hematologic malignancy, meaning cancers of the blood and bone marrow such as leukemias and lymphomas, were each associated with higher anxiety and depression symptom scores. The finding on sex is consistent with a large body of psychiatric epidemiology showing elevated rates of anxiety and depression among women, while the association with hematologic malignancies may reflect the particular intensity and prolonged course of treatments such as chemotherapy and stem cell transplantation. Lower educational attainment is often interpreted as a marker of fewer psychological and material resources for coping with a life-threatening diagnosis.

Perhaps the most telling negative result, however, concerned the opioid outcome itself. None of those variables, female sex, lower educational attainment, or hematologic malignancy, was significantly associated with problematic opioid use once the analyses were completed. In other words, the demographic and clinical profile that predicts who becomes psychologically distressed does not predict who develops problematic opioid use. What predicted problematic use, at least in this dataset, was the psychiatric symptom burden itself. That pattern hints at a possible psychological mechanism: opioids are potent anxiolytics and mood-altering substances, and patients wrestling with untreated depression or anxiety may be more vulnerable to using them in ways that extend beyond pain control, whether by escalating doses, using them for emotional relief, or continuing them beyond clinical need.

The authors are careful about what their design can and cannot show. Because the study is cross-sectional, capturing a single moment in time rather than following patients forward, causal relationships cannot be inferred. It is entirely possible that problematic opioid use contributes to depression and anxiety, that psychological distress drives problematic use, or that a third factor, such as poorly controlled cancer pain, drives both. Reverse causation is a live possibility in any cross-sectional study of this kind, and the correlation coefficients, while statistically robust, cannot adjudicate among these competing explanations. Longitudinal cohort designs, in which patients are assessed repeatedly from diagnosis through treatment, would be needed to establish the direction of the arrow.

Even with those caveats, the clinical implications are hard to ignore. The authors argue that their findings support routine psychological assessment as a standard component of cancer care, alongside integrated psycho-oncology services embedded within the oncology team rather than bolted on as an afterthought. The logic is straightforward: if roughly forty percent of patients in an oncology ward carry clinically significant anxiety or depression, and if that distress is correlated with harmful patterns of opioid use, then screening for mood symptoms is not merely a matter of comfort or quality of life. It becomes a patient-safety intervention, one that could identify, early on, the individuals at heightened risk of misusing the very medications that palliative and pain medicine depend upon.

The setting of the study matters as well. Iran occupies a distinctive position in the global landscape of opioid availability and policy, with a long history of both high opioid consumption for medical purposes and one of the world’s most severe opioid overdose crises driven by illicit substances. A tertiary referral hospital in the north of the country serves a large, diverse patient population, and the fact that the association between psychiatric distress and problematic opioid use appears there, in a health system quite different from those of North America or Western Europe, suggests the phenomenon is not an artifact of any single country’s prescribing culture. Cancer pain management worldwide walks a narrow line between undertreatment, which leaves patients suffering, and overprescription, which can seed dependence and misuse, and this study suggests that psychological distress is a variable that tips the balance in ways clinicians rarely measure.

What would a research agenda built on these findings look like? The authors’ own framing points toward several next steps: prospective studies that track distress and opioid use over the course of treatment, interventions that pair pain management with psychological therapy, and validation of screening tools such as the HADS and DAST-10 in oncology settings across different languages and health systems. The study received no specific external funding, was approved by the ethics committee of Babol University of Medical Sciences, and was conducted with written informed consent from all participants in accordance with the Declaration of Helsinki. Its message, however, extends well beyond its regional origins. For the millions of people living with cancer around the world, pain and despair often arrive together, and the study’s central lesson is that treating one while ignoring the other may undermine both. Integrated care, in which psychiatrists, oncologists, and pain specialists work from the same chart and the same understanding of the patient, is not a luxury. On this evidence, it may be the difference between relief and risk.

Subject of Research: The association between depression, anxiety, and problematic opioid use among adults with cancer

Article Title: Association between depression, anxiety, and problematic opioid use among adults with cancer at a tertiary referral hospital in northern Iran

Article References: Amani, I., Khorshidian, F., Nabipour, M., Hamidia, A., & Bijani, A. (2026). Association between depression, anxiety, and problematic opioid use among adults with cancer at a tertiary referral hospital in northern Iran. Discover Mental Health. https://doi.org/10.1007/s44192-026-00606-1

Image Credits: AI Generated

DOI: 10.1007/s44192-026-00606-1

Keywords: cancer, depression, anxiety, problematic opioid use, psycho-oncology, HADS, DAST-10, cross-sectional study, Iran, mental health, palliative care, DSM-5