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Opioid prescriptions after surgery are effective for pain management but have been a significant contributor to the current opioid epidemic. Our objective is to review pragmatic approaches to develop and implement evidence-based guidelines based on a learning health system model.During the last 2 years there has been a preponderance of data demonstrating that opioids are overprescribed after surgery. This contributes to a number of adverse outcomes, including diversion of leftover pills in the community and rising rates of opioid use disorder.We conducted a MEDLINE/PubMed review of published examples and reviewed our institutional experience in developing and implementing evidence-based postoperative prescribing recommendations.Thirty studies have described collecting data regarding opioid prescribing and patient-reported use in a cohort of 13,591 patients. Three studies describe successful implementation of opioid prescribing recommendations based on patient-reported opioid use. These settings utilized learning health system principles to establish a cycle of quality improvement based on data generated from routine practice. Key components of this pathway were collecting patient-reported outcomes, identifying key stakeholders, and continual assessment. These pathways were rapidly adopted and resulted in a 37% to 63% reduction in prescribing without increasing requests for refills or patient-reported pain scores.A pathway for creating evidence-based opioid-prescribing recommendations can be utilized in diverse practice environments and can lead to significantly decreased opioid prescribing without adversely affecting patient outcomes.