The principles of MI-OUD, including collaboration, compassion, acceptance, and evocation, may conflict with confrontational approaches to behavior change that are familiar to many patients, such as the 12-Step Approach. While many patients appreciate MI-OUD's non-judgmental stance, some who are used to other approaches may take time to transition to it.

Gold standard MI-OUD fidelity monitoring often requires listening to patient encounters. One qualitative study of addiction specialty programs found that clinic leaders believed patients would be apprehensive about having their sessions recorded for fidelity monitoring. Of note, this study did not interview patients, so it is not possible to confirm whether patients actually felt apprehensive.