This academic paper examines rural hospitals' implementation of opioid stewardship program (OSP) elements in Arizona and assesses differences in implementation in emergency department and acute inpatient departments. Some OSP elements were in place in nearly every Arizona critical access hospital, while others were present in only a quarter or a third of hospitals, suggesting that more attention is needed to define and standardize OSPs to prevent unnecessary opioid initiation while simultaneously treating opioid use disorder as necessary.