I want to bring awareness to addiction but explain it in words that we use every day. I will use words like desire, willpower, and intention. In the scientific community, this is known as folk psychology, but there is nothing wrong with this. Although “desire” is a dopaminergic signal found within the mesolimbic system, we want to understand the experience of addiction and not the neuron.
After understanding addiction, it should become clear that compassion and accountability are more appropriate responses to dealing with alcoholics and addicts than demonization and punishment. Furthermore, addiction meets all of the definitional requirements of being a disease—that is, a part of their addiction is out of their control—which makes punitive measures ineffective in the long run.
The Survival Center
Put simply, drugs and alcohol are compelling because they hijack the precise mechanisms that evolved for sex. 
Those that come from alcoholics anonymous get lost in their literature and believe that they must follow the twelve steps word-for-word as if life depended upon it. In fact, the original steps were written in six steps. The point is that the overarching mechanism that keeps them clean is probably the group consciousness that makes them adopt new norms that using is not acceptable.
In the process of working the steps, the parts of the mind that have an obsession with the substance become dormant like a muscle that atrophies when not used. When these parts don’t get used, then the desire to use and the cues associated with using become weakened. They don’t, however, completely go away which is why, arguably, once an addict, then always an addict (i).
The reason addicts develop strong desires to use in the first place is that they are hijacking their survival center. This pleasure center (ii) has a dense source of dopamine receptors within the nucleus accumbens and dorsal striatum, and it makes us want and desire things such as caloric-rich foods, sex, and material items. Drugs and alcohol, unfortunately, target the same part of the brain.
Judgment becomes nothing more than the projection of the strongest desire. 
In short, we have intentions, desires, and beliefs that interact with one another to create a behavior or action. This system is controlled by our willpower. Think of willpower as a skill or a muscle that becomes easier to use when used often and well-rested. When we resist temptation, it is not because we use good judgment but rather we use willpower in order to stick with our intentions.
The problem with addicts is not their willpower but that the desire to use is stronger than what we would experience in normal temptation. Not only is their desire stronger but the desire is decoupled from reasoning, which means that reasoning is near impotent (iii). This does not mean that addicts don’t reason, but when they reason and make choices it will always be biased.
In normal temptation, a person may desire chocolate and indulge by giving in to the urge. In order to do this, they perform a judgment shift. A judgment shift is when we place a higher value on what we would gain if we gave in to temptation and a lower value if we were not to give in. We do this by finding reasons to give in to temptation which reduces our cognitive dissonance.
As an interesting aside, if our intention was to not give in to temptation, then our desire was victorious but we couldn’t say that we went against our better judgment. We could even say that our decision was rational since when making the choice to indulge or not, we gave ourselves reasons why to indulge. This although is reason-based rationality and not the rationality that we are familiar with.
Desire works by capturing the user’s attention, focusing on what is desired, and narrowing horizons. 
When the addict, on the other hand, makes a judgment on whether or not to use, there is such a disparity between the two that not using won’t be tempting. It is not as if the addict doesn’t realize that the choice to use has consequences but rather the desire to use is much more tempting than to not use. In fact, the desire is so overwhelming that the consequences feel like a walk in a park.
The only hope for an addict is that their willpower to resist is strong and the desire to use isn’t strong, which occurs with abstinence. If they try to engage in reasoning, it will be a rationalization or judgment shift in favor of the more desirable (iii). The use of the word choice just doesn’t make sense for an addict because the feeling to use is heavily anchored, which will bias the decision or choice.
In normal circumstances when our desires aren’t overwhelming, I suppose we can call it a choice when we stick with our intentions in the face of a contrary desire. That is, we chose to not give in to temptation and instead chose the right path. But I don’t think that is what is going on here. Because the one that chose correctly may have just had a weak desire, a strong will, and intentions not to.
Hate But Still Want
There must be an almost complete disconnection between judging an outcome good and wanting it, or, conversely, between judging it bad and not wanting it. 
The addict after time will start to hate the substance yet still want it. Not surprisingly experiments show that liking (hating) and wanting (not wanting) are distinct phenomena but work under the same motivational system. For an addict, these two feelings become decoupled as one doesn’t affect the other. So no matter how much they hate it or think it is “bad” they will still want it.
All of the above discussion assumes a degree of severity in the addict’s addiction which depends on how often they have used, how long, what the substance is, and their own genetics. Depending upon the stages and severity of the addiction, the disparity between the value assigned to using and not using will diminish and start looking more like a choice as the more they chose not to use.
The interesting thing is why would an addict or alcoholic choose to use years after sobriety. That is to say what if their intentions change and they decide to use despite having the belief that using will result in consequences. After all, our intentions, wherever they come from, motivate us directly and don’t require us to have a desire. This is where the complexity lies, see addendum.
Addiction Is Immoral
If we think of people in categorical ways, then we can label an obese person and an addict as lazy and weak. After all, it’s their biology and choices that got them there. But if we allow science to illuminate the details of human behavior, we won’t resort to a black-and-white reading—instead, we will understand addiction as a mechanism and not a moral failing that deserves contempt.
I am not suggesting that we give up labels because they describe what we observe. Addicts and alcoholics are downright weak when they succumb to substances in order to cope with the pains that life serves them. They destroy the lives of family members and become a burden to society. If morality is about the wellbeing of others, then they certainly qualify as being immoral beings.
This viewpoint, however, serves our interests and not the addict or alcoholics. To help, we must remove morality from the equation. If we label them as immoral and punish them, then they will only hide their addiction better. Our penal institutions are a sham for the addict and our attitudes are misguided. It is time we let science speak and give them a fighting chance to become moral beings.
i) This means that addicts and alcoholics will often “pick up where they left off” if they start using again. But this isn’t destiny since the wanting of the substance becomes lessened while they learn how to not act on that want.
ii) This is somewhat a misnomer because dopamine is about “wanting”, and it’s the opioid receptors that give “pleasure”.
iii) This is when an addict is in the active stages of addiction.
- intention – enables us to resolve deliberative uncertainty in order to facilitate action
- judgments – evaluation or appraisal of what is best
- desire – a state that preoccupies an agent’s attention with an urge to perform an action
- willpower or self-control – when one sticks with their intentions in the face of contrary desires
- weak-willed – when one revises their intentions too readily and can be due to either having one’s willpower depleted or other factors
- choice – when the situation arises of what to do
 Richard Holton. “Willing, Wanting, Waiting.”
 McGonigal Ph.D., Kelly. “The Willpower Instinct.”
 Miller, Shannon. “The ASAM Principles of Addiction Medicine.”
 Morgan, Oliver J. “Addiction, Attachment, Trauma and Recovery.”
 Wilson, Gary. “Your Brain on Porn.”
WMDKitty -- Survivor says
Maybe therapy targeted towards compulsive behavior disorders would help?
Absolutely. The term desire that I use for an addict or alcoholic becomes a compulsion in that there is not much time to make a decision and an action occurs quickly. The same medications to control obsessive-compulsive behavior have been used, along with CBT therapy to learn how to not act on the obsession. The medication of choice for OCD is SSRIs, for serotonin puts the breaks on obsessive thinking, but since depression usually cooccurs with substance abuse, then I suspect that the biggest benefit is to combat poor mood. Although OCD and substance abuse both involve obsessive and compulsive aspects, their origins in the brain are different. [edited]
Disclaimer: I come to this discussion as an alcoholic’s kid, so I present a very specific viewpoint. I should also add that I’m German, so while the system here sure isn’t the best, there are a lot more options for addicts than the US has, starting with health insurance.
You are absolutely right: Judging and punishment don’t work shit, and compassion and accountability are much more effective, but as usual, the devil lies in the detail.
For one thing, the people who are closest to them will at some point run out of compassion. It’s hard to be compassionate with the person who abused you and who keeps hurting you. This part:
rings absolutely true, and you cannot imagine how much it sucks when destroying whatever relationship you have with your kids, when missing your grandchildren’s birthday, when probably killing yourself is seen as an acceptable price for a glass of gin. Oh, sure, when my mother is dry she feels very sorry, but mostly for herself, which leads me to the next big problem: accountability.
Not just addicts, but many people see accountability and consequences as punishment. In order for accountability to work, the addict needs to understand that there are consequences to their behaviour. Yet at least my mother doesn’t do accountability herself. Accountability happens to other people. Back when her long time alcoholism* spiralled out of control, and my sister and I finally realised that our mother was indeed an alcoholic, she played the blame game, back then with the help of our co-dependant father. We got blamed for her drinking. Especially me, as I decided that she would no longer have frequent and unsupervised access to my children.
Things got better, things got worse, things got better and now they’re worse again. Yes, we did everything to make it possible for her to shelter from Covid (because we still love her, only that love isn’t enough) so that as as soon as she was fully vaccinated she could go out and buy alcohol. Which means that I’m withdrawing. She knows fully well that I will not visit with the kids when she’s drinking, but rather than seeing this as a consequence of her behaviour, she sees it as me being mean and punishing her.
So yeah, forgive me if I sound bitter, but the conclusion is that addiction sucks and that recovery is long, difficult, and often fails despite people having access to support.
* As a kid I didn’t even realise that both my parents’ drinking habits were already problematic. You’re a kid and you grow up thinking that alcohol is what adults drink. I was past 30 when I finally woke up to the fact that my mother was quite often drunk.