Implementation and adaptation of clinical quality improvement opioid measures

•Health systems better understood their opioid prescribing practices, measured care processes, and moved toward improvement.•Health systems prioritized their quality improvement efforts on long-term opioid therapy measures.•Few systems used days’ supply, and instead used number of pills dispensed or number of opioid prescriptions.•Health systems deconstructed measures, focused on high daily dosages, and leveraged treatment agreements.•Health systems developed EHR functionality, supplemented EHR data with chart review, or used other custom supports.