The Zuckerberg San Francisco General Hospital & Trauma Center’s Emergency Department Alternatives to Opioid Program (ZSFG ED-ALT) project aims to increase utilization of opioid alternatives to treat acute pain and improve screening and treatment of patients with opioid use disorder (OUD). We will complete these goals by integrating opioid alternatives into ED clinicians’ daily workflow. We will also use the novel tool of substance use navigation to build on our current addiction care infrastructure to more effectively identify patients with OUD, initiate medications for opioid use disorder (MOUD), and link patients with OUD to outpatient care at a partnering clinic site. ZSFG serves an urban, inner city, and underserved patient population as San Francisco’s safety net hospital. It is the only Level 1 trauma center serving the city of San Francisco, and the emergency department sees approximately 75,000 patients per year. ZSFG is also home to the Family Health Center Bridge Clinic, a clinic dedicated to the timely care and follow-up of recently discharged ED patients with substance use disorders. Of patients who present to the ZSFG ED with pain, abdominal pain, chest pain, headache, extremity fractures/pain, and musculoskeletal pain (including back pain) are the most common. In addition, in the last year, approximately 3000 patients presented to the ZSFG ED with OUD while only a small proportion (21%) were started on MOUD and 11-30% are linked to care. Over the course of three years, our goals for ZSFG ED-ALT are as follows: (1) to establish a multidisciplinary workgroup to create treatment algorithms for the five most common painful conditions presenting to the ZSFG ED. These algorithms will integrate non-opioid medication-based therapies into the ED electronic health record, including order panels for automation. Our goals are also (2) to provide an education curriculum to all ED clinicians (physician faculty, residents, fellows, advanced practice providers) regarding alternatives to opioids practice, the current algorithms for the selected 5 conditions, provision of patient-centered and equitable care, and best practices on treatment of patients with opioid use disorder (including MOUD); (3) to assess the effectiveness of an ED clinician education curriculum regarding ED-ALT; (4) disseminate our findings to the larger ED community, and (5) use an in-ED substance use navigator for improved ED screening for OUD, real-time daily clinician guidance regarding treatment of patients with OUD, motivational interviewing for patients with OUD, and effective referral and linkage to outpatient care. Measured objectives include: order panel usage, and clinician knowledge and capability to provide patients in pain with non-opioid management. Additional objectives/measures related to patients with OUD include: number of patients screened, number of those screened positive who are started on MOUD, and number of those who had successful linkage to outpatient care. Over the course of 3 years, ZSFG ED-ALT will serve 1250 unduplicated patients with acutely painful conditions and/or OUD. Our goals are to (1) train 100% of all ED staff by the end of the project period, (2) at least 50% of all patient who present with one of five most common painful conditions receive medications from the order set (3) at least 50% of all ED patients with OUD started on treatment with MOUD, and (4) at least 50% of patients started on MOUD are linked to care. Project staff are multidisciplinary, highly trained and recognized leaders in program implementation, department-wide education, addiction medicine and pharmacotherapy.