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Purpose: The opioid epidemic in the United States continues to grow, particularly impacting rural communities served by critical access hospitals (CAHs) in Maine. Buprenorphine is an effective medication for the treatment of opioid use disorder (OUD) that can be successfully initiated in the emergency department (ED). However, many EDs have not implemented programs to initiate buprenorphine. This study sought to identify barriers and facilitators to successful implementation of buprenorphine programs inCAH EDs. Methods: Semistructured interviews were conducted with ED directors of Maine CAHs regarding barriers and facilitators to developing programs for ED‐initiated buprenorphine. Seventeen Maine CAH EDs exist and 11 of their directors agreed to participate and completed interviews, which were audio‐recorded, transcribed, and analyzed using a thematic approach. Results: Four themes and 11 subthemes were identified, including (1) compelled to act—directors' personal experiences with patients facilitated the development of buprenorphine programs in their EDs; (2) leadership and mentorship—peer mentorship from other CAH ED directors facilitated, and senior hospital administrators facilitated, or created a barrier in some cases; (3) stigma—fear that EDs would be overcrowded by drug‐seeking patients was a common barrier; and (4) follow‐up—finding appropriate outpatient follow‐up for OUD patients created the greatest logistical barrier. Discussion: ED directors' clinical experience with OUD patients, supportive hospital leadership, and peer mentorship facilitated ED‐initiated buprenorphine programs in rural Maine CAH EDs. Overcoming stigma, developing community outreach, and appropriate follow‐up were the greatest barriers. Future research should focus on enhancing peer mentorship, administrative support, community outreach, and staff education. [ABSTRACT FROM AUTHOR]