Standard Versus High Dose ED-Initiated Buprenorphine Induction

Inclusion Criteria: All patients enrolled into the study must: 1. Be 18-65 years of age. 2. Be treated in the ED during study screening hours. 3. Meet DSM-5 diagnostic criteria for moderate to severe OUD. 4. Have a Clinical Opiate Withdrawal Scale (COWS) score of ≥8 at enrollment (including 2 objective signs of withdrawal at enrollment). 5. Have a urine toxicology test that is positive for opioids. 6. Be able to speak English sufficiently to understand the study procedures and provide written informed consent to participate in the study. Exclusion Criteria: All patients enrolled into the study must not: 1. Have a medical or psychiatric condition that requires hospitalization at the time of index ED visit. 2. Have a known hypersensitivity reaction to buprenorphine/naloxone 3. Be actively suicidal or severely cognitively impaired precluding informed consent. 4. Require ongoing prescription for opioid analgesics. 5. Have a physical exam or reported history consistent with severe liver failure 6. Have a positive urine test for methadone and reported use in the past 72 hours 7. Be a prisoner or in police custody at the time of index ED visit. 8. Be unwilling to follow study procedures (e.g., unwilling to provide permission to contact referral provider/program or unavailable for the follow-up assessments) 9. Have prior enrollment in the current study. 10. Receiving MOUD treatment within the past 7 days. 11. Be pregnant as determined by human gonadotropin (hCG) testing at the index ED visit 12. Have a respiratory rate \<8 or oxygen saturation \<93% 13. Be a participant in any other clinical trial in which medications are being delivered or the use of an investigational drug or device within the last 30 days