Traditional buprenorphine induction requires patients to be in moderate withdrawal to avoid precipitated withdrawal, a painful syndrome that can deter treatment engagement. This creates a dilemma for ED patients who are not in withdrawal or have recently received naloxone, as they face delays in starting medication for opioid use disorder (MOUD). This pilot study demonstrates that a 72-hour EDOU protocol using low-dose "microdosing" approach achieved 66% treatment success, substantially higher than outpatient low-dose protocols (34-36%). The supervised EDOU setting likely contributed to this success by allowing dose titration, managing side effects, and providing continuous support during a vulnerable period. The protocol's key advantage is flexibility, as it can be initiated at any time regardless of withdrawal status, potentially expanding treatment access for patients who would otherwise be turned away. However, the 24% overall retention at 30 days highlights the persistent challenge of maintaining engagement beyond initiation, suggesting that successful induction alone is insufficient without robust linkage to ongoing care. The 54% retention rate among BUP-XR patients suggests extended-release formulations may improve adherence. Important limitations include the small sample size, single-center design, lack of a control group, and potential selection bias favoring motivated patients. Not all EDs have observation units capable of 72-hour stays, limiting generalizability. However, given the substantial burden of untreated OUD in emergency settings and high mortality risk following ED discharge, dedicated EDOU pathways for MOUD initiation represent a promising harm reduction strategy that warrants further investigation in larger, controlled trials.