Buprenorphine is a cornerstone medication for opioid use disorder (OUD) but carries a known risk of precipitated withdrawal (PW) during initiation, a concern that appears to be increasing in the era of nonpharmaceutical fentanyl (NPF). Kawasaki and colleagues report findings from a 2023–2024 nationally representative survey of 396 US buprenorphine prescribers examining challenges with buprenorphine initiation among patients with NPF exposure. Nearly three-quarters of respondents reported difficulty initiating buprenorphine in the prior year, more than half reported at least one episode of PW, and two-thirds reported modifying standard initiation protocols. A notable minority reported frequent unsuccessful initiations requiring transition to methadone, particularly in noninpatient settings.