Considering recent growth in substance abuse among rural populations and the documented scarcity of rural health resources, this study examines the distribution of substance abuse treatment services across the continuum of rural and urban counties, identifying the type and intensity of services provided. Using the 2004 National Survey of Substance Abuse Treatment Services linked to the 2003 Rural-Urban Continuum Codes, we found few substance abuse treatment facilities operating outside of urban and rural adjacent areas and limited availability of intensive services across rural areas. This situation is particularly striking for opioid treatment programs, which are nearly absent in rural areas. The narrow range of services available in rural areas may preclude an individualized treatment approach and long-term follow-up recommended by professional organizations and other experts. The greater proportion of rural-based facilities accepting public payers and providing discounted care may reflect higher rates of uninsurance and underinsurance.