Although opioid use rates are comparable in rural and urban counties, rural opioid users tend to be younger, unmarried, have lower incomes, and are more likely to lack health insurance, all vulnerabilities that may negatively impact their ability to seek treatment and recover. Additionally, the rural healthcare system is characterized by numerous resource, workforce, access, and geographic challenges that complicate the delivery of specialized care for opioid use disorders (OUDs) in rural communities. The nature and scope of the opioid crisis vary across rural communities and require multifaceted, community-based strategies to address the problem. Based on interviews with key stakeholders in Indiana, North Carolina, Vermont, and Washington State, this qualitative study explores promising state and community strategies to tackle the opioid crisis in rural communities and identifies rural challenges to the provision of OUD prevention, treatment, and recovery services.