Things I Think About When I Think About Running (and Morphine)

This episode starts on a Sydney oval before sunrise.

Kate reflects on her weekly Wednesday run — the quiet rituals of turning up, the characters who share the track, the sociology of shared spaces, and the reminder that the ability to move your body is never something to take for granted.

From there, the conversation moves into medicine.

After watching The Pitt, Kate unpacks a common myth about morphine in palliative care — the persistent idea that opioids given at the end of life hasten death. Drawing on her experience in palliative care pharmacy, she explains how opioids are actually used to relieve pain and breathlessness, why addiction is not the issue people think it is, and how careful dosing can restore comfort and dignity for patients.

Finally, with winter approaching, Kate walks through the 2026 influenza vaccine rollout in Australia — explaining why flu vaccines change every year, why all vaccines are now trivalent, and how the different options (Influvac, Flucelvax, Fluzone High-Dose and FluMist) work.

Along the way, she explores the idea that healthcare decisions rarely affect just one person — whether it’s medication myths, palliative care, or vaccination — we’re all part of a much bigger chain.

Evidence-based medicine, midlife health, and a few observations from running laps in the dark.

Follow Kate for more no-nonsense health education at @prescribeorpass on Instagram, Tiktok and Facebook. 

Transcript

SPEAKER_00 0:00

You're listening to On the Moans, where we have conversations about hormones, midlife, and the moments that make us wonder is it just me? I'm Kate. I'm a 48-year-old pharmacist and newly minted perimenopausal oversharer. This is where we talk openly about the changes we aren't prepared for, so we never have to feel alone in them again. I acknowledge the Camaragle people of the Iora Nation, the traditional custodians of the land which I am recording today. I pay my respects to elders past and present, and I extend that respect to all Aboriginal and Torres Strait Islander peoples listening. Always was, always will be, Aboriginal land. I'm sitting on my back deck in the gorgeous Sydney autumn weather, and there's a light breeze, and the wind chimes are dinging away, and the birds are singing in the trees, and I'm looking out over the valley and the bush to the waters of Sydney Harbour, and I'm counting my blessings today. There's a book by the Japanese author Horuki Murakami called What I Talk About When I Talk About Running. Every time I go for my Wednesday morning run around the oval, I find myself thinking about that title because when you run laps, your brain just sort of wanders. I know, I know, I should be fully focused on my form and my pace and my breathing, blah blah blah, whatever. I'm not going to the Olympics, so it probably doesn't matter too much, and I like to be alone with my thoughts sometimes. Gives me the chance to notice things. Think about the little moments. Observe people. So I thought I'd start this episode with a few things I think about when I think about running. Every Wednesday morning I meet a group at the Oval at quarter to six. This time of year it's still dark. We do fartlick training, pacework, the sort of thing I would absolutely never motivate myself to do alone. But if other people are expecting to see you, you show up. And then once I'm there, the motivation takes care of itself. We have our established places in the group, much like pack horses. I'm towards the back of the pack pace-wise, which is totally fine. I have my group within the group, and we help each other around the oval. Someone leads one lap and then we swap. Opportunity for a chat until we start pushing the pace, and then it's a matter of breathing. High fives and fist pumps and a round of congratulations, go us at the end. Today's episode was ten laps, increasing in pace every two laps, finishing at what the coach calls half marathon pace. Now, I understand half marathon effort to be the pace at which I would aspirationally run a half marathon. Because if it was my actual half marathon pace, it would be a very pedestrian speed for sure. But I'm pretty sure he means start slow and increase as you feel. Then we did a set of 500 meters, 400 meters, 300 meters with jog recovery back to the start line. And that was the session. 6.77 kilometers, an average of 5 minutes and 18 seconds per kilometer, including the war map. Bank it. Some wakes you feel amazing. Last week I felt fast and flowy. Today not so much. Legs were heavy, and my right knee reminded me of its existence at every foot strike, which got a bit tedious by the end. But it doesn't really matter, because the point is that I showed up and moved my body. I've been on testosterone for about five months now, along with estrogen and progesterone, and I do feel stronger. I'm lifting heavier at the gym and my running pace has improved. Now, whether that's the hormones or just the fact that I keep turning up, who knows? I've been with this group for about two years now, so you'd think that consistency would count for something, right? But either way, it's motivating. It's good to still be able to improve at physical things as you look down the barrel of turning 50. And honestly, being able to run laps around an oval in a healthy body is a privilege that isn't lost on me. Yesterday I visited a patient in palliative care, 64 years old, just a girl, as my 99-year-old grandmother would have said. She could barely walk from the couch to the doorway to collect her medications. Oxygen tubing, walker, completely breathless. Now, she is palliating with a horrible cancer, not to mention a bunch of other issues like heart failure and chronic kidney disease, but it is a reality check when you see how much work she has to put in just across the room. Running laps in the early morning dark is not to be taken for granted. Our little runny group is a mix of people. A 61-year-old lady who is unbelievably strong and still running marathons. Women get stronger with age. I maintain this. There's a reason ultrarunning is populated with older women. Its endurance built up over a lifetime, I reckon. We have some elite ultra runners in their 30s and 40s who are proper athletes, who make the podium when they compete. And my friend who has just restarted chemotherapy after a cancer occurrence. And she still comes along and jog walks around the oval at whatever pace she can manage. Another reminder that good health is not a given, but a gift to be cherished. There's another group that trains there too, the young ones in their early twenties, tiny shorts, scrunch bum tights, the men all running shirtless, beautiful and ridiculous and full of life. We love to poke gentle fun at this group. Imagine if one week we all came dressed like them, we would say to each other, and we mean in cropped bra tops with stringy straps and matching tight tights and colourful runners, our brand new tattoos proudly displayed on our tan shoulders. But actually, we've been around for long enough to know that if you're out there running, then you're doing a good job. Whatever the pace, whatever the outfit. It's not all sunshine and rainbows, however. Occasionally, things happen. Like this morning. When you run laps around an oval with multiple groups, there's a kind of unwritten code of conduct. Everyone runs counterclockwise, and if you're making your effort, you run on the white line. If you're warming up or cooling down or jogging recovery, you move off the line, either to the inside of the oval or out towards the fence, so the people doing the pacework can get past. By and large, everyone mostly understands this. So I was making my effort running on the line, and there was a group of young guys from the other training group jogging their recovery on the inside of the track, just chatting away. As I came up from behind them to pass, one of them turned his head to the right because all of his friends were on the left, and spat. Now, unfortunately for both of us, that's exactly where I was at that moment. So he spat directly on me. Now, I'm not proud of what happened next, but I did let fly with a fairly impressive string of expletives. To his credit, he was completely shocked and immediately apologetic. Clearly he hadn't seen me, I mean he didn't do it on purpose, even I could see that. I kept running, I mean, I'd made my displeasure apparent, and what else was there to do? But it did make me think about something. When you're moving through shared spaces, whether it's a running oval, a gym, a hospital ward, driving on the road, or honestly just the world, there's a responsibility to be aware of the people around you, to notice where you are in relation to others, because if you're not paying attention, sometimes the impact of what you're doing lands on somebody else. And occasionally, quite literally. Another thing I've noticed at the oval is what I call human spatial decision making, or the lack thereof. The oval we run around is also an AFL field. We start our session at quarter to six in the morning and we run until about 6.35 or 6.40. At 6.30, a private girls' school AFL team arrives to train. They've booked the oval, their coaches come out and start setting up cones and drills in the middle of the field, which makes perfect sense, because all the runners, maybe 20 or 30 of us, are running around the white line on the outside of the oval. The entire middle of the field is completely empty. So far, so good. But then comes the warm-up. The girls line up along the AFL goal posts, which are positioned exactly on the white line where everyone is running, and they start doing these knees-up lunging warm-up drills directly into the running space. Now, just to paint the picture, 20 runners circling the white line doing pacework, the entire middle of the oval completely empty, and 30 schoolgirls lined up exactly on the running line. I always find it so funny. Because you'd think, if you're the coach, surely you can see what's happening. You can see all the people who have been running there since 6 o'clock, you can see the white line is clearly the running lane, and you can see the entire centre of the oval is empty. And you also know that by 6.35, most people will be gone anyway. Happens every week. So why not warm up in the middle of the oval and then move the drills to the whole field once the runners have left? But no, every week they choose one strip of grass that is already in use. It's like some kind of sociological experiment in how humans occupy space, and I find it endlessly entertaining. So today's episode isn't actually about running, but these are a few things I found myself thinking about this morning while running around an oval in the dark. I have to say, I'm really enjoying The Pit. My husband and I watched season one and absolutely loved it, and now we're watching season two and loving it just as much. My husband is a doctor, so one of our favourite things is trying to diagnose the patient in real time along with the team. And, to the show's credit, he's been really complimentary about how accurate the cases reflect what actually happens in real life. The pit has built a reputation for realism, and season two is airing now. If you haven't seen it, I highly recommend. But there was one moment where, for me, they really missed the mark. And spoiler alert here, there's a patient with advanced cancer who comes into the emergency department and is ultimately palliated in a private room. And look, I understand what the writers were trying to do dramatically speaking, but the way they handled the medications felt off. They framed it as, we're going to give her 10 milligrams of morphine, but this might slow her breathing and could hasten her death. And I'm sitting there thinking, this is not a very accurate portrayal of palliative care. Not only that, but in my extensive experience in palliative care, people are wary enough of using opioids. Getting patients and family members to see them as legitimate tools instead of a fast way to a drug addiction is challenging, and we don't need a popular TV series perpetuating this message. Because in reality, if someone is on an end-of-life pathway and you are giving morphine for symptom control, the intention is to relieve pain and or breathlessness. And a dose like 10 milligrams of morphine, especially in that context, is not a dramatic life-ending dose. In fact, 10 milligrams of morphine is a very, very conservative dose, especially for people who, for the most part, are not opioid naive. And the risk of addiction when opiates are used in this context is next to zero. Addiction is a much more complex set of behaviours involving drug seeking and lying and so on. Certainly not what is displayed in palliative care. The way it was presented leaned into that old fear that opioids given in palliative care are basically euthanasia by another name. And that is such an unhelpful myth. And that's what really annoyed me because this show gets so much else right. It captures the chaos of emergency medicine, the pace, the uncertainty, the interpersonal stuff, all of that beautifully. So it stood out even more when they suddenly slipped into this very Hollywood version of end-of-life care, where morphine is treated like the thing that kills the patient rather than the thing that eases suffering as someone is already dying. So, a note to the writers of the pit. Outstanding work overall. Genuinely. But on the palliative care front, I think you missed it. One of the things I've learned working in palliative care is that opioids carry an enormous amount of cultural baggage. People hear the word morphine and they immediately think of addiction, overdose, or that moment in movies where someone is given a final injection and quietly slips away. But in real palliative care practice, opioids are something very different. They are tools. Tools that allow people to breathe more comfortably, move without severe pain, sleep, talk to their families, sit in the garden, sometimes even go home. And when they're used properly, they are one of the most effective medications we have. So today I thought we'd talk about how opioids are actually used in palliative care, because the reality is a lot less dramatic and a lot more thoughtful than what we see on the television. First, let's start with the goal. Palliative care is not about prolonging life at all costs, and it's not about hastening death either. The goal is quality of life. That means managing symptoms like pain, breathlessness, anxiety, restlessness, nausea, cough. And opioids play a particularly important event in two symptoms: pain and breathlessness. Most people understand the pain part, but the breathlessness surprises people. Because opioids like morphine actually reduce the sensation of air hunger in the brain. So, if someone has advanced lung disease, cancer, heart failure, and it feels like they're constantly gasping for air, small doses of opioids can make breathing feel easier. They don't fix the underlying disease, but they relieve the distress of the symptom. Now let's address the elephant in the room: addiction. Families often say, we don't want mum to become an addict to morphine. And I understand where that fear comes from. But addiction is a behavioural disorder. It involves things like compulsive drug seeking, loss of control, continuing to use a substance despite harm. In palliative care, we're treating people who are seriously ill, often nearing the end of life. They are taking medication to relieve symptoms, not to chase a high. So the risk of addiction in this setting is extremely low. What we are aiming for is something very different. We are aiming for comfort. In palliative care, we typically use a small group of opioids. The most common are morphine, hydromorphone, oxycodone, fentanyl, buprenorphine. Morphine is usually the first-line opioid. It's inexpensive, effective, and very well understood. Hydromorphone is often used when patients have kidney impairment or morphine causes problematic side effects or very high doses are required. And a note to clinicians: hydromorphone is five to seven times stronger than morphine, so make sure you've got your dosage calculators out when you're making that conversion. And oxycodone is another alternative that some patients tolerate better. They all work in essentially the same way. They bind to opioid receptors in the brain and spinal cord, reducing the perception of pain and modifying how the brain experiences breathlessness. Another thing that confuses people is the difference between immediate release and slow release opioids. Immediate release opioids work quickly. They're often used when starting therapy for breakthrough pain and when symptoms fluctuate. For example, someone might take immediate release morphine every four hours, or they might have a PRN dose available, meaning they can take it as needed if pain breaks through. Slow release opioids are different. These are taken regularly, usually every 12 to 24 hours. And examples include slow release morphine and slow release oxycodone. These medications provide background symptom control. Then if the pain spikes on top of that, the patient uses breakthrough doses of immediate release medication. It's a bit like baseline coverage plus top-ups when needed. Another important aspect of palliative care is how the medications are given. Many patients start with oral medications, tablets or liquid morphine taken by mouth, but as illness progresses, swallowing can become difficult. That's when we often move to subcutaneous administration. Subcutaneous means the medication is delivered just under the skin, usually through a small cannula. One common method is something called a syringe driver. A syringe driver is a small portable pump that slowly delivers medication over 24 hours. This allows us to provide a steady infusion of medications like morphine or hydromorphone. Additionally, PRN doses can still be given if symptoms flare. Syringe drivers are incredibly helpful because they allow stable symptom control, fewer injections, and greater comfort for the patient. You also may have heard of opioid patches like fentanyl or buprenorphine patches. These stick to the skin and release medication slowly over several days. They're useful in some situations, particularly when swallowing is difficult, pain is stable, and the patient already has an established opioid dose. But patches are not usually the first option in rapidly changing palliative care situations because adjusting the dose quickly can be harder. Now opioids do have side effects. The big ones are constipation, nausea, and drowsiness. Constipation is almost universal with opioids, which is why one of the golden rules of palliative care is if you prescribe an opioid, you prescribe a laxative or a periont. Because once constipation becomes severe, it's much harder to fix. Common options include things like stimulant laxatives, cloxalin center, stool softeners, the colloxal part, or osmotic agents, muvacol, or osmolax. Good bowel management is absolutely critical because unmanaged constipation can become far more distressing than the pain we were trying to treat. Finally, let's talk about the myth that morphine hastens death. This idea is incredibly persistent. But when opioids are used appropriately for symptom control, the evidence shows they do not shorten life. In fact, relieving distressing symptoms can sometimes allow patients to live longer and more comfortably. The intention is not to suppress breathing, the intention is to relieve suffering. And when doses are carefully titrated, starting low, adjusting slowly, opioids are safe and effective. In real life, palliative care with opioids often looks like this. A patient whose pain was unbearable is now comfortable enough to talk with their family. A person who felt like they were suffocating can now breathe. Someone who hasn't slept for days finally rests. It's quiet work, not dramatic, not cinematic, but incredibly meaningful. So when you see morphine used in palliative care, it's not a signal that we've given up, and it's not a signal that someone is being put down. It's a signal that the healthcare team is focusing on what matters most at that stage of life comfort, dignity, relief of suffering, and helping someone live whatever time they have left as well as possible. It's autumn. The nights are getting cooler, and the sunsets are more colourful, and daylight savings is about to end on Easter Sunday. So I thought I'd spend a few minutes talking about something that happens every year around this time in Australia, and that is the annual influenza vaccine rollout. Because every autumn, the same questions start appearing. People say things like, Do I really need to get it every year? Which one should I get? Why are there four different options? Is the expensive one actually better? So let's walk through what's available in Australia for the 2026 flu season, what the differences are, and what Atari, the Australian Technical Advisory Group on Immunisation, actually recommends. First, though, a quick reminder about why flu vaccines change every year. Influenza viruses mutate constantly through something called antigenic drift, which means the immune system's memory of last year's virus doesn't perfectly match this year's. So each year the World Health Organization looks at the strains circulating in the Northern Hemisphere winter, predicts what will be circulating in the Southern Hemisphere winter, and vaccines are formulated accordingly. Which is why last year's flu vaccine doesn't protect you this year. It's not a booster in the traditional sense, it's actually a new vaccine composition every year. One of the most interesting changes for the 2026 influenza season in Australia is that all influenza vaccines have moved from quadrivalent to trivalent formulations. For many years, flu vaccines protected against four strains, two influenza A and two influenza B. But something unusual happened during the COVID pandemic. One of those B lineages, B yamagata, essentially disappeared from global circulation. Since March 2020, it has not been detected in influenza surveillance systems worldwide. Because that lineage is not Circulated for several years, global public health authorities and vaccine manufacturers have now removed it from influenza vaccines. So for the 2026 season, all influenza vaccines in Australia are trivalent, meaning they contain two influenza A and one influenza B. This applies to all the vaccines available this year, including Influvac, Flu Sulvac, Fluzone High Dose, and Flu Mist. What differs between these vaccines is not the strains they contain, but how they are manufactured and how they stimulate the immune system. One option available privately this year is InFluVAC, which is a trivalent egg-based influenza vaccine. This is the traditional way influenza vaccines have been manufactured for decades. Scientists take the selected influenza strain and grow them inside fertilized chicken eggs. The virus replicates inside the egg, then it's harvested, purified, inactivated, and formulated into the vaccine. This technology has been used safely for decades and has protected hundreds of millions of people worldwide. Flucilvax is also trivalent for the 2026 season, containing the same three strains. But instead of growing the virus inside eggs, the virus is grown in mammalian cell cultures in the laboratory. This avoids those egg adaptation mutations and allows the vaccine strain to remain closer to the circulating virus strains. Some studies suggest that in certain seasons this can produce slightly better protection, particularly if egg adaptation affects the match between the vaccine and the circulating virus. Fluzone high dose for older adults. Now, once people reach their mid-60s, the conversation changes slightly. Because the immune system naturally weakens with age, something called immunosinescence, this means standard vaccines sometimes produce a weaker immune response in older adults. One approach to solving this is increasing the antigen dose. That's what the fluzone high-dose vaccine does. For the 2026 season, fluzone is also trivalent, but it contains four times the amount of antigen compared with a standard influenza vaccine. More antigen stimulates a stronger immune response, which translates into better protection against influenza infection, hospitalization, and complications like pneumonia in older adults. Flu mist, the nasal spray vaccine. Flu mist is an intranasal influenza vaccine, meaning instead of the needle in the arm, it's sprayed into the nose. Flu mist is a live attenuated influenza vaccine, meaning it contains a weakened version of the virus that stimulates the immune system without causing disease. Because influenza normally infects through the respiratory tract, delivering the vaccine directly into the nasal mucosa stimulates immunity where the virus naturally enters the body. For 2026 in Australia, Flu Mist is also trivalent and contains the same two A strains and one B strain. It is approved for children and adolescents under the National Immunisation Program. However, because it's a live vaccine, it cannot be given to people with moderate or severe immunocompromise. Under the National Immunisation Programme, many Australians are eligible for free influenza vaccination. This includes adults aged 65 and over, children aged six months to under five years, pregnant women, Aboriginal and Torres Strait Islander people, people with certain chronic medical conditions, and these include conditions like chronic heart disease, chronic lung disease, diabetes, kidney disease, neurological disorders, and immunocompromising conditions. Atagi also notes that this list is not exhaustive and clinicians can include people with similar risk profiles based on clinical judgment. Because influenza isn't just a bad cold, it causes thousands of hospitalizations and hundreds of deaths in Australia every year, particularly among older adults and vulnerable populations. Another common question is when should I get it? Influenza vaccine immunity doesn't last for forever. Antibody levels typically peak around two to four weeks after vaccination when the immune system has fully responded. After that, immunity gradually declines. Protection against infection is generally strongest for the first three to four months and then slowly reduces over about four to six months. Protection against severe disease tends to last longer than protection against mild infection, which is why Otagi recommends vaccination from April onwards, so that your immunity is strongest when flu circulation typically peaks during the Australian winter. But if someone presents later in winter, Atari still recommends vaccinating because some protection is always better than none. From a healthcare perspective, flu vaccination season is also something else. It's a public health opportunity. When someone comes in for their flu vaccine, it's a perfect time to check their other vaccinations. In Australia, we now have several adult vaccinations that people often forget about: COVID boosters, shingle vaccines, RSV vaccines for older adults, and patussis boosters. Clinicians can quickly check this through the Australian Immunisation Register. So sometimes someone comes in for a flu shot and discovers they're actually due for several different vaccines, which is exactly how preventative healthcare should work. So the key takeaways for the 2026 influenza vaccine are flu vaccines change every year because the virus mutates. All vaccines in Australia this year are trivalent, protecting against two A strains and one B strain. The B Yamataga lineage has been removed because it hasn't circulated globally since 2020. Different vaccines use different technologies egg-based, cell-based, high-dose, or nasal spray. Many Australians are eligible for free vaccination under the National Immunisation Programme. And if there's one final thought I'll leave you with, it's this. Influenza vaccines don't just reduce the chance of getting the flu. They significantly reduce the risk of severe illness, hospitalization, and death. And for those of you thinking, I'm pretty healthy, I never get that sick, I probably don't need it, remember that infectious diseases don't just affect individuals, they move through communities. Every infection is part of a chain of transmission. So even if you personally might cope fine with the flu, you may still pass it on to someone who won't. An older adult, a newborn baby, someone on chemotherapy, someone with a chronic lung disease. Getting vaccinated isn't just about protecting yourself, it's about not being the link in the chain that spreads it to someone more vulnerable. Well, the next time you hear the word morphine in the context of palliative care, I hope you don't picture the dramatic movie scene where it's treated like the thing that's ending someone's life. Because in real life, morphine is usually the thing that's allowing someone to breathe more comfortably, sleep, talk to their family, and live whatever time they have left with less suffering. It's a workhorse, not dramatic, but incredibly important. Perhaps a bit like those laps around the oval in the dark. Most of the time, nothing spectacular is happening. People are just moving, breathing, getting through another lap, enjoying being in their bodies even if subconsciously, even if that enjoyment doesn't come until the well-deserved coffee and shower afterwards. Thanks for listening to On the Moans. If you enjoyed this episode, share it with someone who might find it useful. And follow me on TikTok, Instagram, and Facebook at Prescribe or Pass for no nonsense, evidence based educational content. I'll look forward to your company the next time we get on the moans. Bye bye.