J. D. Vance grew up in Middletown, Ohio, where his grandparents had moved during the "hillbilly" migration decades earlier. Many people with Appalachian roots left areas like Jackson, Kentucky during this time, so they brought much of their culture to the Middletown area. Jackson was a coal-mining town which at times had proven to be a sound financial base for its residents. Yet the income proved temporary, and Jackson was and continues to be plagued by poverty. Drug usage is commonplace; Vance's mother is a portrait of the drug addictions which plague those with roots in Jackson.
In some ways, Middletown is different. Its core economic base is Armco, where Vance's Papaw finds employment; the factory manufactures steel. Middleton provides a means for Vance's Papaw to provide for his family and in a way that is substantially better than he could have done in Jackson. Eventually, however, steel production began moving overseas, and Armco loses its strong economic influence within the town. Because this factory was the best employment opportunity in the town, people have almost no other options to earn a decent living. Thus, poverty grips Middletown much as it does Jackson. Few businesses do well simply because there aren't enough jobs to employ eventual consumers of products and services. Streets in downtown Middletown which used to thrive are now used for drug transactions, which is quite similar to the Jackson culture. Vance notes that you don't visit Main Street in Middletown after dark. The extreme poverty of Middletown following the near collapse of its one economic resource is much the same as the poverty Vance's grandparents tried to escape when they left Jackson. Both towns have little economic opportunity to offer their residents, who are thus plagued with feelings of hopelessness and desperation, often turning to drugs to escape from the pains of daily life.