Program Director/Principal Investigator (Last, First, Middle): Brady, Kathleen T PROJECT SUMMARY (See instructions): Why do patients decline buprenorphine from the emergency department?: Add-on study to CTN-0107 Emergency department-initiated buprenorphine (EDIB) successfully doubles retention in treatment at 30 days when compared to referral alone. Additionally, there are significant benefits to treatment with buprenorphine and other medications for opioid use disorder (MOUD) including significant reductions in overdose and all-cause mortality, better retention compared to placebo or no medication increased length of time in recovery, decreased opioid use, decreased craving, and improved social functioning. Emergency departments (EDs) are well-suited to engage patients in buprenorphine treatment, resulting in significantly improved ED quality of care and increased access to this life-saving treatment. Unfortunately, only a minority of patients eligible and offered EDIB receive it. The specific objective of this proposal is to systematically evaluate reasons why EDIB-eligible patients with OUD decline EDIB. This study will be a qualitative study utilizing semi-structured interviews with ED medical providers, ED staff, and patients who are deemed eligible for EDIB to evaluate provider/staff-level and patient-level barriers and facilitators to EDIB acceptance among eligible patients. This knowledge is imperative to public health efforts addressing the opioid epidemic, as results can be used to improve harm reduction interventions by addressing critical gaps for ED patients with OUD. This proposal would be the first to examine why a minority of patients eligible for EDIB accept it when it is available and recommended. This study will provide an important initial step in better understanding reasons for declining EDIB and informing intervention design and implementation to increase EDIB uptake. This study can be completed rapidly and has potential to positively impact the thousands of patients with OUD seen in EDs across the country. Our team of experts in addiction science, survey methods, qualitative data, implementation science and emergency medicine are uniquely qualified to carry out this proposal. RELEVANCE (See instructions): The proposed research will provide the foundation to address systematic problems with ED-initiated buprenorphine programs, which will in turn improve patient engagement in evidenced-based treatments.