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BACKGROUND Although postoperative opioid overprescription has been well-studied, little is known about opioid underprescription. This study aims to determine the extent of improper discharge opioid prescription in patients undergoing general surgery procedures. STUDY DESIGN This retrospective cohort study investigated opioid-naïve adult patients who underwent inpatient general surgery at an academic medical center between June 2012 and December 2019. The primary outcome was the difference between individual patient's inpatient daily oral morphine milligram equivalent (MME) 24 hours before discharge and patient's prescribed daily MME at discharge. Data were analyzed using chi-square, Mann-Whitney, Wilcoxon and Kruskal-Wallis tests and multivariable logistic regression. RESULTS Among 5,531 patients, 58.1% had opioid overprescription and 22.4% had opioid underprescription. Median prescribed daily MME was 311% of median inpatient daily MME in over-prescribed patients and 56.3% of median inpatient daily MME in under-prescribed patients. About half (52.3%) of patients who consumed no opioids on the day before discharge were opioid over-prescribed, and 69.9% of patients who required inpatient daily opioid of > 100 MME were opioid under-prescribed. Opioid under-prescribed patients had an increased opioid refill rate 1-30 days after discharge, whereas opioid over-prescribed patients had an increased refill rate 31-60 days after discharge. From 2017 to 2019, the percentage of over-prescribed patients decreased by 35.8%, but the percentage of under-prescribed patients increased by 42.4%. CONCLUSION Although avoiding postoperative opioid overprescription remains imperative, preventing postoperative opioid underprescription is also essential. We recommend using a patient-centered approach to match the daily dose of opioid prescription with each patient's inpatient daily opioid consumption.