Opioid use disorder (OUD) remains a major source of morbidity and mortality within the United States (US). Emergency department (ED) ED-initiated buprenorphine (BUP) has been shown to increase engagement in treatment and reduced opioid misuse. However, rates of ED BUP initiation are low. This study aims to understand ED attending physician attitudes, beliefs and practices toward BUP initiation. We interviewed a purposive sampling of ED attending providers at two urban, tertiary-care academic EDs within a New York City healthcare system from July 2019 to April 2021. We conducted focused, semi-structured qualitative interviews examining provider background/knowledge, beliefs and attitudes as well as practical and logistical concerns. Our interview guide was created utilizing a grounded theory framework. Three researchers independently coded transcripts using an iterative, open-coding approach. We conducted 14 interviews with physicians who had varying levels of prior experience administering and prescribing BUP. Analytic domains included barriers, facilitators, patient characteristics, provider needs, attitudes/beliefs on addiction and public health implications. Commonly identified barriers to Buprenorphine initiation included training/waiver concerns, perceived lack of institutional support, concerns regarding patient follow-up and logistical barriers. Commonly identified facilitators included prior experience/comfort, sense of duty as a physician and patient motivation. Several interviewees perceived BUP to be superior to methadone and felt this perception increased likelihood of initiating BUP. Several interviewees also identified the role of the ED in treating OUD as a factor in BUP initiation with some viewing this as a facilitator and others as a barrier. Increased ancillary support and institutional protocols for BUP initiation and improved follow-up infrastructure were identified as key provider needs. In this qualitative study of ED attending physicians, we identified facilitators and barriers to initiating BUP in the ED. Interviewees also noted various provider needs for more widespread adoption. Interventions focused on addressing identified barriers and provider needs should be designed and implemented to increase rates of ED buprenorphine administration and initiation.