ABSTRACTBackgroundHealth professionals are responsible for implementing patient involvement (PI) in the choice of treatment approach. Previous studies within the field of substance use disorder (SUD) treatment have shown positive patient experiences with PI. However, little is known about challenges experienced by health professionals in converting principles of PI into clinical practice.AimsTo explore challenges with PI in the treatment of SUD.MethodFive health professionals working in a Norwegian institution for inpatient treatment of SUD were included and took part in a semi-structured interview. Data were analysed using a systematic text condensation approach.ResultsPI in SUD was perceived as challenging due to conceptual unclarities as well as treatment dilemmas that may challenge the notion of PI as a universal and unified ideological foundation of substance use treatment.ConclusionsThe findings point to a need to critically examine the PI concept and to take a flexible approach in adjusting PI principles to good clinical practice. A framework is launched, allowing the reported challenges in implementing PI in clinical practice to be accepted, acknowledged, and recognized by clinicians as well as by administrators and heads of clinical units.