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Postoperative prescribing following acute care surgery must be optimized to limit excess opioids in circulation as misuse and diversion are frequently preceded by a prescription for acute pain. This study aimed to identify patient characteristics associated with higher opioid prescribing following laparoscopic cholecystectomy (LC).Among patients aged 18 years or older who underwent LC at a single institution in 2014 to 2016, opioids prescribed at discharge were converted to oral morphine equivalents (OME) and compared with developing state guidelines (maximum, 200 OME). Preoperative opioid use was defined as any opioid prescription 1 month to 3 months before LC or a prescription unrelated to gallbladder disease less than 1 month before LC. Univariate and multivariable methods determined characteristics associated with top quartile opioid prescriptions among opioid-naive patients.Of 1,606 LC patients, 34% had emergent procedures, and 14% were preoperative opioid users. Nonemergent LC patients were more likely to use opioids preoperatively (16% vs. 11%, p = 0.006), but median OME did not differ by preoperative opioid use (225 vs. 219, p = 0.40). Among 1,376 opioid-naive patients, 96% received opioids at discharge. Median OME was 225 (interquartile range, 150–300), and 52% were prescribed greater than 200 OME. Top quartile prescriptions (≥300 OME) were associated with gallstone pancreatitis diagnosis, younger age, higher pain scores, and longer length of stay (all p < 0.05). While median OME did not differ by emergent status (median, 225; interquartile range, 150–300 for both, p = 0.15), emergent had more top quartile prescriptions (32% vs. 25%, p = 0.005). After adjusting for diagnosis, age, and sex, emergent status showed evidence of being associated with top quartile prescription (odds ratio, 1.3; 95% confidence interval, 1.0–1.8). Thirty-day refill rate was 5%.Over half of opioid-naive patients undergoing LC were prescribed opioids exceeding draft state guidelines. Variation in prescribing patterns was not fully explained by patient factors. Acute care surgeons have an opportunity to optimize prescribing practices with the ultimate goal of reducing opioid misuse.Therapeutic study, level IV; Epidemiologic study, level III.