This study compared the characteristics and treatment outcomes of rural adolescents with urban adolescents in substance abuse treatment programs in CSAT's Strengthening Communities for Youth (SCY) initiative. Using data from ten SCY programs nationally, the authors classified adolescents as rural or urban using Rural-Urban Commuting Area (RUCA) codes. We then evaluated changes in substance use frequency and substance-related problems at three, six, and 12 months after baseline assessments for the two sites that treated rural (n = 59) and urban (n = 345) youth in outpatient settings. Data were analyzed using a two-part mixed effects model for zero-saturated dependent variables. At treatment intake, rural youth exhibited greater problem severity on a number of substance abuse and mental health indices. From intake to the 12-month follow-up point, the percentages of both urban and rural youth who reported abstinence increased significantly. Both rural and urban youth also reported fewer problems due to substance use over time, but differences between groups were not consistent. Overall, treatment appears equally effective for both rural and urban adolescents. As few rural youth obtained treatment, we encourage funding agencies and treatment providers to consider innovative ways for providing services in rural areas and addressing gaps in primary prevention, early identification, and continuing care.