Over the past two decades, the emergency department (ED) has seen an increase in opioid use-related admissions. The ED serves at the frontline of addressing the morbidity and mortality associated with opioid use disorder (OUD). Therefore, it has become a growing consensus that the ED should implement strategies that address OUD and optimize patient outcomes. As such, the observation unit (OU) in the ED has been shown to be an effective site for the observation and management of opioid withdrawal, as well as initiate medication-assisted therapy (MAT). Patients are offered up to 72 hours of MAT doses but are connected to outpatient facilities for long-term management. This initiation in the ED is shown to be more effective in the long-term management of OUD versus referral only. As we continue to manage OUD in the ED, more studies are necessary to establish a standard dosage for buprenorphine therapy, and standardize and solidify MAT initiation in the ED.