Importance: Xylazine is increasingly reported in street drugs and fatal overdoses in the US, yet state-level data are limited, hampering local public health responses.

Question: To what extent is xylazine reported in fatal overdoses and law enforcement drug submissions in different states?

Findings: In this cross-sectional study of US overdose deaths and forensic reports, 16 states had no xylazine forensic reports in 2019, and only 2 states had no xylazine reports in 2022. By 2022 xylazine’s representation in forensic reports had increased in all but 3 states, and at least 43 states reported xylazine-related deaths; among states with data available, xylazine-involved death rates were highest in Vermont and Connecticut in 2022.

Meaning: These results suggest that xylazine forensic reports and overdose deaths are concentrated in eastern states but have increased across the US.